Healthcare Provider Details

I. General information

NPI: 1215977061
Provider Name (Legal Business Name): CHERRY RIDGE GUEST CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5980 CHERRY RIDGE RD
BASTROP LA
71220-1842
US

IV. Provider business mailing address

PO BOX 52389
SHREVEPORT LA
71135-2389
US

V. Phone/Fax

Practice location:
  • Phone: 318-281-6933
  • Fax: 318-281-1734
Mailing address:
  • Phone: 318-798-2648
  • Fax: 318-798-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number867
License Number StateLA

VIII. Authorized Official

Name: MR. KEVIN C GAMBLE
Title or Position: OFFICER
Credential:
Phone: 318-798-2648