1811209232 NPI number — DESOTO HEALTHCARE CENTER INC.

Table of content: (NPI 1811209232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811209232 NPI number — DESOTO HEALTHCARE CENTER INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESOTO HEALTHCARE CENTER INC.
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:
1811209232
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1384
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71052-1384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-871-1633
Provider Business Mailing Address Fax Number:
318-871-1677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
938 LOUISE ST
Provider Second Line Business Practice Location Address:
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:
318-871-1633
Provider Business Practice Location Address Fax Number:
318-871-1677
Provider Enumeration Date:
07/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GANNON
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
FAMILY NURSE PRACTITIONER
Authorized Official Telephone Number:
318-871-1633

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD199935 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RN0300X , with the licence number: 1487481 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 1996971 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 03124 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 020173 , 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: 2117629 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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