Healthcare Provider Details

I. General information

NPI: 1790061224
Provider Name (Legal Business Name): CHERRY RIDGE SKILLED NURSING FACILITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2011
Last Update Date: 11/03/2011
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

1523 TEXAS AVE
BASTROP LA
71220-4043
US

V. Phone/Fax

Practice location:
  • Phone: 318-281-6933
  • Fax: 318-281-1734
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 Number
License Number State

VIII. Authorized Official

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