Healthcare Provider Details

I. General information

NPI: 1710909569
Provider Name (Legal Business Name): CHARLYN ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 POLK ST
WINNSBORO LA
71295-2350
US

IV. Provider business mailing address

804 POLK ST
WINNSBORO LA
71295-2350
US

V. Phone/Fax

Practice location:
  • Phone: 318-435-6116
  • Fax: 318-435-3993
Mailing address:
  • Phone: 318-435-6116
  • Fax: 318-435-3993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number893
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number893
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number893
License Number StateLA

VIII. Authorized Official

Name: MR. DONALD WAYNE HENDERSON
Title or Position: NURSING FACILITY ADMINISTRATOR
Credential:
Phone: 318-435-6116