Healthcare Provider Details

I. General information

NPI: 1902896657
Provider Name (Legal Business Name): CLC OF LAKE PROVIDENCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5976 HIGHWAY 65 N
LAKE PROVIDENCE LA
71254-5235
US

IV. Provider business mailing address

5976 HIGHWAY 65 N
LAKE PROVIDENCE LA
71254-5235
US

V. Phone/Fax

Practice location:
  • Phone: 318-559-4050
  • Fax: 318-559-4052
Mailing address:
  • Phone: 318-559-4050
  • Fax: 318-559-4052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number750
License Number StateLA

VIII. Authorized Official

Name: MR. DOUGLAS M. WRIGHT JR.
Title or Position: MANAGING MEMBER
Credential:
Phone: 662-680-3148