Provider Demographics
NPI:1609861780
Name:MARY GOSS NURSING HOME, INC
Entity type:Organization
Organization Name:MARY GOSS NURSING HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSING FACILITY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EDDYE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-323-9013
Mailing Address - Street 1:PO BOX 4509
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71211-4509
Mailing Address - Country:US
Mailing Address - Phone:318-323-9013
Mailing Address - Fax:318-324-1350
Practice Address - Street 1:3300 WHITE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-5153
Practice Address - Country:US
Practice Address - Phone:318-323-9013
Practice Address - Fax:318-324-1350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA41314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1510327Medicaid
LA1510327Medicaid
LA195596Medicare ID - Type Unspecified