Provider Demographics
NPI:1508805037
Name:HERITAGE MANOR STRATMORE NURSING & REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:HERITAGE MANOR STRATMORE NURSING & REHABILITATION CENTER LLC
Other - Org Name:HERITAGE MANOR OF STRATMORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-709-1408
Mailing Address - Street 1:530 STRATMORE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-3020
Mailing Address - Country:US
Mailing Address - Phone:318-524-0187
Mailing Address - Fax:318-524-2029
Practice Address - Street 1:530 STRATMORE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-3020
Practice Address - Country:US
Practice Address - Phone:318-524-0187
Practice Address - Fax:318-524-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA774314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1521396Medicaid
LA1521396Medicaid