1194768762 NPI number — PLANTATION MANAGEMENT COMPANY, LLC

Table of content: (NPI 1194768762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194768762 NPI number — PLANTATION MANAGEMENT COMPANY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLANTATION MANAGEMENT COMPANY, 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:
GOLDEN AGE HEALTHCARE AND REHABILITATION
Provider Other Organization Name Type Code:
3
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:
1194768762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 VETERANS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENHAM SPRINGS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70726-4722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-665-5544
Provider Business Mailing Address Fax Number:
225-667-1011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27090 LA HIGHWAY 16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENHAM SPRINGS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70726-7811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-665-5544
Provider Business Practice Location Address Fax Number:
225-667-1011
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DELATTE
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
COMPTROLLER
Authorized Official Telephone Number:
225-664-6697

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 160 , 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: 1518158 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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