Healthcare Provider Details

I. General information

NPI: 1780770719
Provider Name (Legal Business Name): PONCHATOULA NURSING HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15704 MEDICAL ARTS DR
HAMMOND LA
70403-1446
US

IV. Provider business mailing address

15704 MEDICAL ARTS DR
HAMMOND LA
70403-1446
US

V. Phone/Fax

Practice location:
  • Phone: 985-542-0110
  • Fax: 985-542-8619
Mailing address:
  • Phone: 985-542-0110
  • Fax: 985-542-8619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number856
License Number StateLA

VIII. Authorized Official

Name: MR. ELWOOD PAUL GUITREAU JR.
Title or Position: ADMINISTRATOR
Credential:
Phone: 985-542-0110