MEDICARE: CLC OF LAKE PROVIDENCE, 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	750	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902896657
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLC OF LAKE PROVIDENCE, LLC

Provider Business Mailing Address
First Line	:	5976 HIGHWAY 65 N
Second Line	:
City	:	LAKE PROVIDENCE
State	:	LA
Zip	:	71254-5235
Country	:	US
Telephone Number	:	318-559-4050
Fax Number	:	318-559-4052

Provider Business Practice Location Address
First Line	:	5976 HIGHWAY 65 N
Second Line	:
City	:	LAKE PROVIDENCE
State	:	LA
Zip	:	71254-5235
Country	:	US
Telephone Number	:	318-559-4050
Fax Number	:	318-559-4052

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. DOUGLAS M. WRIGHT JR.
Credential	:
Telephone Number	:	662-680-3148

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	01/28/2008

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Directions to “CLC OF LAKE PROVIDENCE, LLC ” Practice Location

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