Healthcare Provider Details

I. General information

NPI: 1992786024
Provider Name (Legal Business Name): HICKORY MANOR NURSING & REHABILITATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 08/22/2020
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

PO BOX 69
BASTROP LA
71221-0069
US

V. Phone/Fax

Practice location:
  • Phone: 318-281-6523
  • Fax: 318-283-1097
Mailing address:
  • Phone: 318-281-6523
  • Fax: 318-283-1097

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: MR. TEDDY RAY PRICE
Title or Position: MANAGING MEMBER
Credential:
Phone: 318-628-4116