Healthcare Provider Details

I. General information

NPI: 1114908308
Provider Name (Legal Business Name): COLONIAL MANOR GUEST HOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WHATLEY ST
RAYVILLE LA
71269-3318
US

IV. Provider business mailing address

PO BOX 874
RAYVILLE LA
71269-0874
US

V. Phone/Fax

Practice location:
  • Phone: 318-728-3252
  • Fax: 318-728-6552
Mailing address:
  • Phone: 318-728-3252
  • Fax: 318-728-6552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number233
License Number StateLA

VIII. Authorized Official

Name: MR. TEDDY RAY PRICE
Title or Position: MANAGING MEMBER
Credential:
Phone: 318-628-4116