Healthcare Provider Details

I. General information

NPI: 1689666489
Provider Name (Legal Business Name): TRI-STATE HEALTH SERVICES OF CENLA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 BAILEY AVE
HAYNESVILLE LA
71038-5411
US

IV. Provider business mailing address

PO BOX 12486
ALEXANDRIA LA
71315-2486
US

V. Phone/Fax

Practice location:
  • Phone: 318-624-1166
  • Fax: 318-624-0269
Mailing address:
  • Phone: 318-448-8778
  • Fax: 318-448-8895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number772
License Number StateLA

VIII. Authorized Official

Name: MR. TOLLIE BORDEAUX
Title or Position: OWNER
Credential:
Phone: 318-448-8778