Provider Demographics
NPI:1063512903
Name:PORT ALLEN CARE CENTER, LLC
Entity type:Organization
Organization Name:PORT ALLEN CARE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:D
Authorized Official - Last Name:GUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-800-4955
Mailing Address - Street 1:403 N 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEN
Mailing Address - State:LA
Mailing Address - Zip Code:70767-2264
Mailing Address - Country:US
Mailing Address - Phone:225-346-8815
Mailing Address - Fax:225-346-8989
Practice Address - Street 1:403 N 15TH ST
Practice Address - Street 2:
Practice Address - City:PORT ALLEN
Practice Address - State:LA
Practice Address - Zip Code:70767-2264
Practice Address - Country:US
Practice Address - Phone:225-346-8815
Practice Address - Fax:225-346-8989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA385314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1520039Medicaid
LA1520039Medicaid