Provider Demographics
NPI:1770541088
Name:COMMUNITY CARE CENTER OF DESTREHAN LLC
Entity type:Organization
Organization Name:COMMUNITY CARE CENTER OF DESTREHAN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-709-1408
Mailing Address - Street 1:22 PLANTATION RD
Mailing Address - Street 2:
Mailing Address - City:DESTREHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70047-3013
Mailing Address - Country:US
Mailing Address - Phone:985-164-1793
Mailing Address - Fax:985-764-1374
Practice Address - Street 1:22 PLANTATION RD
Practice Address - Street 2:
Practice Address - City:DESTREHAN
Practice Address - State:LA
Practice Address - Zip Code:70047-3013
Practice Address - Country:US
Practice Address - Phone:985-164-1793
Practice Address - Fax:985-764-1374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA803314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA60529OtherBUE CROSS BLUE SHIELD
LA1510122Medicaid
LA195221Medicare Oscar/Certification