1427039585 NPI number — WYATT MANOR NURSING & REHABILITATION CENTER, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427039585 NPI number — WYATT MANOR NURSING & REHABILITATION CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYATT MANOR NURSING & REHABILITATION 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:
6
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:
1427039585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 279
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71251-0279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-259-2814
Provider Business Mailing Address Fax Number:
318-259-8439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4659 HIGHWAY 505
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71251-5891
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-259-2814
Provider Business Practice Location Address Fax Number:
318-259-8439
Provider Enumeration Date:
11/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PRICE
Authorized Official First Name:
TEDDY
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
318-628-4116

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  151 , 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: 19E202 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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