Provider Demographics
NPI:1881746204
Name:PLAQUEMINE MANOR NURSING HOME, INC.
Entity type:Organization
Organization Name:PLAQUEMINE MANOR NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BOB
Authorized Official - Middle Name:G
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:225-343-9152
Mailing Address - Street 1:24320 FERDINAND ST
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-3634
Mailing Address - Country:US
Mailing Address - Phone:225-387-1345
Mailing Address - Fax:
Practice Address - Street 1:24320 FERDINAND ST
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-3634
Practice Address - Country:US
Practice Address - Phone:225-387-1345
Practice Address - Fax:225-687-4778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA106314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA51773Medicaid
LA195329Medicare ID - Type UnspecifiedMEDICARE PROVIDER #