Provider Demographics
NPI:1730124488
Name:VIRGINIA HALL NURSING HOME
Entity Type:Organization
Organization Name:VIRGINIA HALL NURSING HOME
Other - Org Name:PROGRESSIVE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BOYTER
Authorized Official - Suffix:
Authorized Official - Credentials:NFA
Authorized Official - Phone:318-212-6461
Mailing Address - Street 1:2715 ALBERT L BICKNELL DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3925
Mailing Address - Country:US
Mailing Address - Phone:318-212-8200
Mailing Address - Fax:318-212-8220
Practice Address - Street 1:2715 ALBERT L BICKNELL DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3925
Practice Address - Country:US
Practice Address - Phone:318-212-8200
Practice Address - Fax:318-212-8220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA284314000000X
LA332BN1400X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1516597Medicaid
LA195136Medicare ID - Type Unspecified
LA1516597Medicaid