Healthcare Provider Details

I. General information

NPI: 1609861780
Provider Name (Legal Business Name): MARY GOSS NURSING HOME, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 WHITE ST
MONROE LA
71203-5153
US

IV. Provider business mailing address

PO BOX 4509
MONROE LA
71211-4509
US

V. Phone/Fax

Practice location:
  • Phone: 318-323-9013
  • Fax: 318-324-1350
Mailing address:
  • Phone: 318-323-9013
  • Fax: 318-324-1350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number41
License Number StateLA

VIII. Authorized Official

Name: EDDYE LOUISE DAVIS
Title or Position: NURSING FACILITY ADMINISTRATOR
Credential:
Phone: 318-323-9013