=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467657304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEAST LOUISANA VETERANS HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2007
-----------------------------------------------------
Last Update Date | 10/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6700 HIGHWAY 165 N
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71203-8753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-362-4206
-----------------------------------------------------
Fax | 318-362-4241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6700 HIGHWAY 165 N
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71203-8753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-362-4206
-----------------------------------------------------
Fax | 318-362-4241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT CFO
-----------------------------------------------------
Name | MRS. YOLANDA HOLMAN
-----------------------------------------------------
Credential | AO
-----------------------------------------------------
Telephone | 318-362-4206
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------