Provider Demographics
NPI:1730284811
Name:LULING LIVING CENTER
Entity type:Organization
Organization Name:LULING LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GUILLOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-644-4853
Mailing Address - Street 1:1039 E HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-4757
Mailing Address - Country:US
Mailing Address - Phone:225-644-4853
Mailing Address - Fax:225-647-9658
Practice Address - Street 1:1125 PAUL MAILLARD RD
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-4351
Practice Address - Country:US
Practice Address - Phone:985-785-8271
Practice Address - Fax:985-785-9944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA810314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1510181Medicaid
LA1510181Medicaid