=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033777479
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHSHORE EXTENDED CARE HOSPITAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2019
-----------------------------------------------------
Last Update Date | 05/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64030 LA 434
-----------------------------------------------------
City | LACOMBE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-218-4700
-----------------------------------------------------
Fax | 985-218-4701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 51266
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70505-1266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-233-1307
-----------------------------------------------------
Fax | 337-233-5764
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DONALD D. STELLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 337-233-1307
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282E00000X
-----------------------------------------------------
Taxonomy Name | Long Term Care Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------