MEDICARE: MARTIN DE PORRES NURSING HOME, INC

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	231	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	:	1538159033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARTIN DE PORRES NURSING HOME, INC

Provider Business Mailing Address
First Line	:	200 TEAL ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70615-6841
Country	:	US
Telephone Number	:	337-439-5761
Fax Number	:	337-433-4788

Provider Business Practice Location Address
First Line	:	200 TEAL ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70615-6841
Country	:	US
Telephone Number	:	337-439-5761
Fax Number	:	337-466-4788

Authorized Official
Title or Position	:	ASSISTANT EXECUTIVE DIRECTOR
Name	:	BILL BREWER
Credential	:
Telephone Number	:	337-439-5761

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	08/22/2020

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