Healthcare Provider Details

I. General information

NPI: 1316262264
Provider Name (Legal Business Name): HICKORY MANOR SKILLED NURSING FACILITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 04/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 W HICKORY AVE
BASTROP LA
71220-4442
US

IV. Provider business mailing address

1523 TEXAS AVE
BASTROP LA
71220-4043
US

V. Phone/Fax

Practice location:
  • Phone: 318-281-6523
  • Fax:
Mailing address:
  • Phone: 318-281-0078
  • Fax: 318-281-2753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number196
License Number StateLA

VIII. Authorized Official

Name: CHARLES GOODWIN GLADNEY
Title or Position: MANAGING PARTNER
Credential:
Phone: 318-281-0078