1215977061 NPI number — CHERRY RIDGE GUEST CARE, LLC

Table of content: (NPI 1215977061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215977061 NPI number — CHERRY RIDGE GUEST CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHERRY RIDGE GUEST CARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215977061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 52389
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71135-2389
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-798-2648
Provider Business Mailing Address Fax Number:
318-798-3451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5980 CHERRY RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BASTROP
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71220-1842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-281-6933
Provider Business Practice Location Address Fax Number:
318-281-1734
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GAMBLE
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
318-798-2648

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  867 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1515001 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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