Healthcare Provider Details

I. General information

NPI: 1770541922
Provider Name (Legal Business Name): HERITAGE MANOR WEST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7060 COTTON WOOD ST
SHREVEPORT LA
71129-2722
US

IV. Provider business mailing address

7060 COTTON WOOD ST
SHREVEPORT LA
71129-2722
US

V. Phone/Fax

Practice location:
  • Phone: 318-631-1846
  • Fax: 318-636-2824
Mailing address:
  • Phone: 318-631-1846
  • Fax: 318-636-2824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2203782206
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number2203782206
License Number StateLA

VIII. Authorized Official

Name: MRS. TONI PARKINSON
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 60170914708