Provider Demographics
NPI:1689666489
Name:TRI-STATE HEALTH SERVICES OF CENLA, LLC
Entity Type:Organization
Organization Name:TRI-STATE HEALTH SERVICES OF CENLA, LLC
Other - Org Name:HERITAGE NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOLLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BORDEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-448-8778
Mailing Address - Street 1:PO BOX 12486
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71315-2486
Mailing Address - Country:US
Mailing Address - Phone:318-448-8778
Mailing Address - Fax:318-448-8895
Practice Address - Street 1:1745 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:HAYNESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71038-5411
Practice Address - Country:US
Practice Address - Phone:318-624-1166
Practice Address - Fax:318-624-0269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA772314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1521183Medicaid
LA30377OtherBLUE CROSS
LA30377OtherBLUE CROSS