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General NPI Number Information
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NPI Number | 1487870366
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Entity Type | Organization
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Legal Business Name | SENIORS CLUB
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 06/23/2008
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Provider Practice Location Address
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Address Line | 2653 MALCOLM ST
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City | SHREVEPORT
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State | LA
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Zip | 71108-2720
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Country | US
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Telephone | 318-635-0010
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Fax | 318-635-8844
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Provider Business Mailing Address
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Address Line | 2653 MALCOLM ST
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City | SHREVEPORT
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State | LA
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Zip | 71108-2720
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Country | US
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Telephone | 318-635-0010
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Fax | 318-635-8844
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. KAREN R. MCCOY
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Credential | RN
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Telephone | 318-635-0010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number | 7392
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License Number State | LA
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