Basic Information
| Provider Information | |||||||||
| NPI: | 1174664833 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACER HEALTH MANAGEMENT CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SOUTH CAMERON MEMORIAL LONGTERM CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5360 WEST CREOLE HWY | ||||||||
| Address2: | |||||||||
| City: | CAMERON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706315127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375424111 | ||||||||
| FaxNumber: | 3375424110 | ||||||||
| Practice Location | |||||||||
| Address1: | 5360 WEST CREOLE HWY | ||||||||
| Address2: | |||||||||
| City: | CAMERON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706315127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375424111 | ||||||||
| FaxNumber: | 3375424110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 02/07/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHOEMAKER | ||||||||
| AuthorizedOfficialFirstName: | RAY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6628400196 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PACER HEALTH MANAGEMENT CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 534 | LA | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 1510874 | 05 | LA | MEDICAID | 30985 | 01 | LA | BCBS | OTHER | 30985 | 01 | LA | BLUE CROSS | OTHER |