1710909569 NPI number — CHARLYN ENTERPRISES, LLC

Table of content: (NPI 1710909569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710909569 NPI number — CHARLYN ENTERPRISES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLYN ENTERPRISES, 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:
CHARLYN REHABILITATION & NURSING CENTER
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:
1710909569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 POLK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINNSBORO
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71295-2350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-435-6116
Provider Business Mailing Address Fax Number:
318-435-3993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
804 POLK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINNSBORO
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71295-2350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-435-6116
Provider Business Practice Location Address Fax Number:
318-435-3993
Provider Enumeration Date:
07/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
NURSING FACILITY ADMINISTRATOR
Authorized Official Telephone Number:
318-435-6116

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  893 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BN1400X , with the licence number: 893 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X , with the licence number: 893 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1514926 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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