Healthcare Provider Details

I. General information

NPI: 1730124488
Provider Name (Legal Business Name): VIRGINIA HALL NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 ALBERT L BICKNELL DR
SHREVEPORT LA
71103-3925
US

IV. Provider business mailing address

2715 ALBERT L BICKNELL DR
SHREVEPORT LA
71103-3925
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-8200
  • Fax: 318-212-8220
Mailing address:
  • Phone: 318-212-8200
  • Fax: 318-212-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number284
License Number StateLA

VIII. Authorized Official

Name: MR. RICHARD EUGENE BOYTER
Title or Position: ADMINISTRATOR
Credential: N.F.A.
Phone: 318-212-6461