MEDICARE: COMMUNITY CARE CENTER OF DESTREHAN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	803	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	60529	OTHER	LA	BUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770541088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE CENTER OF DESTREHAN LLC

Provider Business Mailing Address
First Line	:	22 PLANTATION RD
Second Line	:
City	:	DESTREHAN
State	:	LA
Zip	:	70047-3013
Country	:	US
Telephone Number	:	985-164-1793
Fax Number	:	985-764-1374

Provider Business Practice Location Address
First Line	:	22 PLANTATION RD
Second Line	:
City	:	DESTREHAN
State	:	LA
Zip	:	70047-3013
Country	:	US
Telephone Number	:	985-164-1793
Fax Number	:	985-764-1374

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	MS. TONI PARKINSON
Credential	:
Telephone Number	:	601-709-1408

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	11/30/2024

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