MEDICARE: HERITAGE MANOR WEST 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	385H00000X	Respite Care	2203782206	LA
2	314000000X	Skilled Nursing Facility	2203782206	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
2	30406	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1770541922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE MANOR WEST LLC

Provider Business Mailing Address
First Line	:	7060 COTTON WOOD ST
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71129-2722
Country	:	US
Telephone Number	:	318-631-1846
Fax Number	:	318-636-2824

Provider Business Practice Location Address
First Line	:	7060 COTTON WOOD ST
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71129-2722
Country	:	US
Telephone Number	:	318-631-1846
Fax Number	:	318-636-2824

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	MRS. TONI PARKINSON
Credential	:
Telephone Number	:	60170914708

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	06/22/2015

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Directions to “HERITAGE MANOR WEST LLC ” Practice Location

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