Healthcare Provider Details

I. General information

NPI: 1023075355
Provider Name (Legal Business Name): COMMUNITY CARE CENTER OF THIBODAUX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 11/30/2024
Certification Date: 11/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 AUDUBON AVE
THIBODAUX LA
70301-5014
US

IV. Provider business mailing address

2110 AUDUBON AVE
THIBODAUX LA
70301-5014
US

V. Phone/Fax

Practice location:
  • Phone: 985-446-3975
  • Fax: 985-447-5329
Mailing address:
  • Phone: 985-446-3975
  • Fax: 985-447-5329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number766
License Number StateLA

VIII. Authorized Official

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