Provider Demographics
NPI:1942291778
Name:ST. AGNES HEALTHCARE & REHAB CENTER,INC.
Entity Type:Organization
Organization Name:ST. AGNES HEALTHCARE & REHAB CENTER,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-332-4808
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-0010
Mailing Address - Country:US
Mailing Address - Phone:337-332-4808
Mailing Address - Fax:337-332-2897
Practice Address - Street 1:606 LATIOLAIS DR
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-4231
Practice Address - Country:US
Practice Address - Phone:337-332-4808
Practice Address - Fax:337-332-2897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA423314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1516252Medicaid
LA195313Medicare ID - Type Unspecified