Basic Information
| Provider Information | |||||||||
| NPI: | 1164479697 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. LANDRY EXTENDED CARE HOSPITAL, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 W PINHOOK RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372331307 | ||||||||
| FaxNumber: | 3372335764 | ||||||||
| Practice Location | |||||||||
| Address1: | 539 E PRUDHOMME ST | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | OPELOUSAS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705706499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379485184 | ||||||||
| FaxNumber: | 3379483294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MYERS | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
| AuthorizedOfficialTelephone: | 3372331307 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 479 | LA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1700461 | 05 | LA | MEDICAID |