Provider Demographics
NPI:1770541922
Name:HERITAGE MANOR WEST LLC
Entity type:Organization
Organization Name:HERITAGE MANOR WEST LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:6017-091-4708
Mailing Address - Street 1:7060 COTTON WOOD ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-2722
Mailing Address - Country:US
Mailing Address - Phone:318-631-1846
Mailing Address - Fax:318-636-2824
Practice Address - Street 1:7060 COTTON WOOD ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-2722
Practice Address - Country:US
Practice Address - Phone:318-631-1846
Practice Address - Fax:318-636-2824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203782206385H00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1521493Medicaid
30406OtherBLUE CROSS BLUE SHIELD
195447Medicare Oscar/Certification
LA1521493Medicaid