Provider Demographics
NPI:1598872640
Name:PONTCHARTRAIN GUEST HOUSE INC
Entity Type:Organization
Organization Name:PONTCHARTRAIN GUEST HOUSE INC
Other - Org Name:PONTCHARTRAIN HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-626-1900
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-0338
Mailing Address - Country:US
Mailing Address - Phone:985-626-1900
Mailing Address - Fax:985-727-9660
Practice Address - Street 1:1401 FLORIDA ST
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-5433
Practice Address - Country:US
Practice Address - Phone:985-626-8581
Practice Address - Fax:985-624-9478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA312314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1513784Medicaid
LA1513784Medicaid