1861488751 NPI number — GRACE NURSING HOME INC

Table of content: (NPI 1861488751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861488751 NPI number — GRACE NURSING HOME INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE NURSING HOME 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:
GRACE HEALTH AND REHABILITATION 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:
1861488751
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 945
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70722-0945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-683-8533
Provider Business Mailing Address Fax Number:
225-683-3222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9725 GRACE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70722-4925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-683-8533
Provider Business Practice Location Address Fax Number:
225-683-3222
Provider Enumeration Date:
09/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SAINT
Authorized Official First Name:
SIDNEY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
225-683-8533

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  370 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 370 , 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: 1515094 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33857 . This is a "BLUE CROSS BLUE SHIELD LA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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