Provider Demographics
NPI:1972502185
Name:OLLIE STEELE BURDEN MANOR, INC
Entity Type:Organization
Organization Name:OLLIE STEELE BURDEN MANOR, INC
Other - Org Name:ST. CLARE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-216-3604
Mailing Address - Street 1:7435 BISHOP OTT DRIVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-8930
Mailing Address - Country:US
Mailing Address - Phone:225-216-3604
Mailing Address - Fax:225-216-3746
Practice Address - Street 1:7435 BISHOP OTT DRIVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-8930
Practice Address - Country:US
Practice Address - Phone:225-216-3604
Practice Address - Fax:225-216-3746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X, 332BN1400X, 332BP3500X
LA718314000000X
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
LA1520969Medicaid
LA195590Medicare Oscar/Certification
LA80429Medicare PIN
LA1520969Medicaid