Provider Demographics
NPI:1720038961
Name:KENTWOOD MANOR NURSING HOME, L.L.C.
Entity Type:Organization
Organization Name:KENTWOOD MANOR NURSING HOME, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:318-445-6470
Mailing Address - Street 1:PO BOX 8055
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71306-1055
Mailing Address - Country:US
Mailing Address - Phone:318-445-6470
Mailing Address - Fax:318-445-6422
Practice Address - Street 1:921 AVENUE G
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:LA
Practice Address - Zip Code:70444-2636
Practice Address - Country:US
Practice Address - Phone:985-229-2112
Practice Address - Fax:985-229-6922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA927314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1515027Medicaid
195543Medicare ID - Type Unspecified