1255521183 NPI number — SUPERIOR HOSPICE OF NORTHWEST LOUISIANA, LLC

Table of content: (NPI 1255521183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255521183 NPI number — SUPERIOR HOSPICE OF NORTHWEST LOUISIANA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPERIOR HOSPICE OF NORTHWEST LOUISIANA, 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:
1255521183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1523 TEXAS AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BASTROP
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71220-4043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-281-0078
Provider Business Mailing Address Fax Number:
318-281-2753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 JENKINS ST.
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-872-2000
Provider Business Practice Location Address Fax Number:
318-872-2001
Provider Enumeration Date:
07/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GLADNEY
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
G
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
318-281-0078

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  TBD , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251G00000X , with the licence number: 238 , 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: 468572 . This is a "JOINT COMMISSION HCO ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1381179 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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