Provider Demographics
NPI:1366168973
Name:2907 BASILE SNF LLC
Entity type:Organization
Organization Name:2907 BASILE SNF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:337-270-9090
Mailing Address - Street 1:2100 VEROT SCHOOL RD STE 4
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6466
Mailing Address - Country:US
Mailing Address - Phone:337-270-9090
Mailing Address - Fax:337-270-9038
Practice Address - Street 1:2907 SCHAMBERS ST
Practice Address - Street 2:
Practice Address - City:BASILE
Practice Address - State:LA
Practice Address - Zip Code:70515-5445
Practice Address - Country:US
Practice Address - Phone:337-432-6663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility