MEDICARE: PILGRIM MANOR GUEST CARE CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	873	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063454338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PILGRIM MANOR GUEST CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 52389
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71135-2389
Country	:	US
Telephone Number	:	318-798-2648
Fax Number	:	318-798-3451

Provider Business Practice Location Address
First Line	:	1524 DOCTORS DR
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-3322
Country	:	US
Telephone Number	:	318-742-1623
Fax Number	:	318-742-2878

Authorized Official
Title or Position	:	OFFICER
Name	:	MR. KEVIN C GAMBLE
Credential	:
Telephone Number	:	318-798-2648

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	08/27/2010

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