Healthcare Provider Details

I. General information

NPI: 1700472313
Provider Name (Legal Business Name): LA WESTFORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 WESTFORK DR
BATON ROUGE LA
70816-2290
US

IV. Provider business mailing address

24641 US HIGHWAY 19 N
CLEARWATER FL
33763-5007
US

V. Phone/Fax

Practice location:
  • Phone: 225-291-7049
  • Fax:
Mailing address:
  • Phone: 727-210-0781
  • Fax:

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. ROY B BRIDGES
Title or Position: AUTHORIZED AGENT
Credential:
Phone: 727-330-2801