Provider Demographics
NPI:1790061224
Name:CHERRY RIDGE SKILLED NURSING FACILITY, LLC
Entity Type:Organization
Organization Name:CHERRY RIDGE SKILLED NURSING FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:GOODWIN
Authorized Official - Last Name:GLADNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-281-0078
Mailing Address - Street 1:1523 TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-4043
Mailing Address - Country:US
Mailing Address - Phone:318-281-0078
Mailing Address - Fax:318-281-2753
Practice Address - Street 1:5980 CHERRY RIDGE RD
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-1842
Practice Address - Country:US
Practice Address - Phone:318-281-6933
Practice Address - Fax:318-281-1734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-28
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1515001Medicaid
LA1515001Medicaid