Basic Information
| Provider Information | |||||||||
| NPI: | 1073648853 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOOKER T. WASHINGTON GUEST CARE CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 52389 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711352389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187982648 | ||||||||
| FaxNumber: | 3187983451 | ||||||||
| Practice Location | |||||||||
| Address1: | 7605 LINE AVE. | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711065162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182192608 | ||||||||
| FaxNumber: | 3188617685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 06/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | GAMBLE | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3187982648 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 993 | LA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1510076 | 05 | LA | MEDICAID |