Provider Demographics
NPI:1740268739
Name:CARROLL NURSING HOME
Entity type:Organization
Organization Name:CARROLL NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:C
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-428-3249
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:LA
Mailing Address - Zip Code:71263-0788
Mailing Address - Country:US
Mailing Address - Phone:318-428-3249
Mailing Address - Fax:
Practice Address - Street 1:307 N. CASTLEMAN ST
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:LA
Practice Address - Zip Code:71263
Practice Address - Country:US
Practice Address - Phone:318-428-3249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA165313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1511595Medicaid
LA34848OtherBLUE CROSS
LA34848OtherBLUE CROSS