Healthcare Provider Details

I. General information

NPI: 1083662944
Provider Name (Legal Business Name): COMMUNITY CARE CENTER OF SHREVEPORT SOUTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 11/30/2024
Certification Date: 11/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9712 MANSFIELD RD
SHREVEPORT LA
71118-4406
US

IV. Provider business mailing address

9712 MANSFIELD RD
SHREVEPORT LA
71118-4498
US

V. Phone/Fax

Practice location:
  • Phone: 318-687-2080
  • Fax: 318-688-8103
Mailing address:
  • Phone: 318-687-2080
  • Fax: 318-688-8103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number784
License Number StateLA

VIII. Authorized Official

Name: MS. TONI PARKINSON
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 601-709-1408