Healthcare Provider Details

I. General information

NPI: 1891778981
Provider Name (Legal Business Name): PRAIRIE MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 EDWIN ELLIOTT DR.
PINE PRAIRIE LA
70576
US

IV. Provider business mailing address

PO BOX 500 1050 EDWIN ELLIOT DR.
PINE PRAIRIE LA
70576-0500
US

V. Phone/Fax

Practice location:
  • Phone: 337-599-2031
  • Fax: 337-599-2548
Mailing address:
  • Phone: 337-599-2031
  • Fax: 337-599-2548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number452
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MS. SANDRA BOOK
Title or Position: ADMINISTRATOR
Credential:
Phone: 337-599-2031