Provider Demographics
NPI:1386628220
Name:CHRISTIAN VILLA NURSING HOME
Entity Type:Organization
Organization Name:CHRISTIAN VILLA NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:337-783-5533
Mailing Address - Street 1:PO BOX 540
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70527-0540
Mailing Address - Country:US
Mailing Address - Phone:337-783-5533
Mailing Address - Fax:337-785-2219
Practice Address - Street 1:1120 W HUTCHINSON AVE
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-4124
Practice Address - Country:US
Practice Address - Phone:337-783-5533
Practice Address - Fax:337-785-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1512656Medicaid
LA195426Medicare ID - Type Unspecified