MEDICARE: JACKSON MANOR 1691 TENANT, 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	865	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	:	1861491466
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON MANOR 1691 TENANT, LLC

Provider Business Mailing Address
First Line	:	1691 S HUDSON AVE
Second Line	:
City	:	JONESBORO
State	:	LA
Zip	:	71251-5856
Country	:	US
Telephone Number	:	318-259-7386
Fax Number	:	318-259-4644

Provider Business Practice Location Address
First Line	:	1691 S HUDSON AVE
Second Line	:
City	:	JONESBORO
State	:	LA
Zip	:	71251-5856
Country	:	US
Telephone Number	:	318-259-7386
Fax Number	:	318-259-4644

Authorized Official
Title or Position	:	COO
Name	:	MR. ALEX PALEY
Credential	:
Telephone Number	:	914-390-4363

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	02/12/2008

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