Provider Demographics
NPI:1992786024
Name:HICKORY MANOR NURSING & REHABILITATION CENTER, LLC
Entity type:Organization
Organization Name:HICKORY MANOR NURSING & REHABILITATION CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:TEDDY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-628-4116
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-0069
Mailing Address - Country:US
Mailing Address - Phone:318-281-6523
Mailing Address - Fax:318-283-1097
Practice Address - Street 1:370 W HICKORY AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4442
Practice Address - Country:US
Practice Address - Phone:318-281-6523
Practice Address - Fax:318-283-1097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA196314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1520756Medicaid
LA195461Medicare ID - Type Unspecified