Healthcare Provider Details

I. General information

NPI: 1770635211
Provider Name (Legal Business Name): SOUTHEAST LOUISIANA VETERANS HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4080 W AIRLINE HWY
RESERVE LA
70084-5712
US

IV. Provider business mailing address

4080 W AIRLINE HWY
RESERVE LA
70084-5712
US

V. Phone/Fax

Practice location:
  • Phone: 985-479-4080
  • Fax: 985-479-4090
Mailing address:
  • Phone: 985-479-4080
  • Fax: 985-479-4090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateLA

VIII. Authorized Official

Name: MR. CLEVELAND J OBEY JR.
Title or Position: LTC ADMINISTRATOR
Credential:
Phone: 985-479-4080