Provider Demographics
NPI:1366594798
Name:MAISON DEVILLE NURSING HOME OF OPELOUSAS, INC.
Entity type:Organization
Organization Name:MAISON DEVILLE NURSING HOME OF OPELOUSAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:G
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:225-343-9152
Mailing Address - Street 1:7941 I-49 SOUTH SERVICE ROAD
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570
Mailing Address - Country:US
Mailing Address - Phone:337-942-7588
Mailing Address - Fax:
Practice Address - Street 1:7941 I-49 SOUTH SERVICE ROAD
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570
Practice Address - Country:US
Practice Address - Phone:337-942-7588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA213314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA52027Medicaid
LA52027Medicaid