Basic Information
| Provider Information | |||||||||
| NPI: | 1184185506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PMG OPCO-GUEST HOUSE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9225 NORMANDIE DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711183249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186860515 | ||||||||
| FaxNumber: | 3186870311 | ||||||||
| Practice Location | |||||||||
| Address1: | 9225 NORMANDIE DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711183249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186860515 | ||||||||
| FaxNumber: | 3186870311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2019 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | BOULWARE | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9724280900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.