NPIMap

Organization Active NPI

PMG Opco-Shreveport LLC

Doing business as Shreveport Manor Skilled Nursing and Rehabilitation

  • Skilled Nursing Facility
  • Shreveport, LA
National Provider Identifier
1376004796
Registry record updated Mar 28, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
PMG OPCO-SHREVEPORT LLC
Doing business as
Shreveport Manor Skilled Nursing and Rehabilitation
Practice address
3302 Mansfield Rd
Shreveport, LA 71103-4106
Phone
(318) 222-9482
Fax
(318) 424-9985
NPI assigned
Mar 28, 2019
Last updated
Mar 28, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 28, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Steven Boulware
Title
Managing Member
Phone
(972) 428-0900

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X NU Primary

Addresses

Primary practice location

3302 Mansfield Rd
Shreveport, LA 71103-4106

Mailing address

3302 Mansfield Rd
Shreveport, LA 71103-4106
Phone (318) 222-9482

Other names 1

  • SHREVEPORT MANOR SKILLED NURSING AND REHABILITATION Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in LA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190424002704 LA Part A Provider - Skilled Nursing Facility 2860734761 Practice locations: Shreveport, LA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1376004796. Details of each certification follow.

Skilled nursing facility certification: CCN 195515

Legal name
PMG OPCO-SHREVEPORT LLC
Doing business as
SHREVEPORT MANOR SKILLED NURSING AND REHABILITATION
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jan 30, 2001
Last certification
Jul 30, 2024
Beds
127
Ownership / control type
Partnership
Organization structure
LLCProprietary
Enrollment address
3302 Mansfield Road
Shreveport, LA 71103-4106
Nursing home name
SHREVEPORT MANOR SKILLED NURSING & REHABILITATION
Affiliated entity
PRIORITY MANAGEMENT

Care Compare: Nursing home

Medicare Care Compare
Listed as
Shreveport Manor Skilled Nursing & RehabilitationCCN 195515 · All quality measures
Overall star rating
1 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
3 of 5
Type
Medicare and Medicaid
Ownership
For profit - Partnership
Certified
Jan 30, 2001
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
12768.3 residents per day on average
Chain
Priority Management38 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Locations

3302 Mansfield Rd
Shreveport, LA 71103
Phone (318) 222-9482

Ownership & related parties

All disclosed owners & managing parties 18

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Douglas B Boulware Individual 5% Or Greater Indirect Ownership Interest Apr 1, 2019 33.34%
Indirect Ownership Interest Apr 1, 2019 33.34%
Organization, Lake Charles, LA LLC Adp of the SNF May 27, 2025
Pat Bass Individual Adp of the SNF Apr 18, 2025
Organization, Lake Charles, LA LLC Adp of the SNF May 27, 2025
Individual Adp of the SNF Apr 1, 2019
Organization, San Clemente, CA Adp of the SNF Apr 1, 2019
Priority Management Group, LLC Organization, Dallas, TX LLC, Management services company, Chain home office Operational/Managerial Control Apr 1, 2019 100%
Adp of the SNF May 27, 2025
James Werner Williams Individual Adp of the SNF Apr 18, 2025
Individual Adp of the SNF Apr 1, 2019
Organization, San Clemente, CA Corporation, Real estate investment trust (REIT) Adp of the SNF Apr 1, 2019
Christina Marie Starr Individual Adp of the SNF Oct 31, 2022
Steven D Boulware Individual 5% Or Greater Indirect Ownership Interest Apr 1, 2019 33.33%
Operational/Managerial ControlAuthorized Official & Managing M Apr 1, 2019 33.33%
Indirect Ownership Interest Apr 1, 2019 33.33%
Organization, Bossier City, LA LLC Adp of the SNF May 27, 2025
SDB Holdings Organization, Bossier City, LA LLC, Holding company, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Apr 1, 2019 100%
Individual Adp of the SNF Apr 1, 2019
Organization, Bossier City, LA LLC, Consulting firm Adp of the SNF May 27, 2025
William M Bauder Individual 5% Or Greater Indirect Ownership InterestManaging Member of Management Co Apr 1, 2019 33.33%
Operational/Managerial ControlManaging Member Apr 1, 2019 33.33%
Indirect Ownership Interest Apr 1, 2019 33.33%
Organization, Dallas, TX LLC Adp of the SNF May 27, 2025

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 22

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 22

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1553731200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1553731200000",
    "number": "1376004796",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3302 MANSFIELD RD",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711034106",
            "telephone_number": "318-222-9482",
            "fax_number": "318-424-9985"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3302 MANSFIELD RD",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711034106",
            "telephone_number": "318-222-9482",
            "fax_number": "318-424-9985"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PMG OPCO-SHREVEPORT LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-03-28",
        "last_updated": "2019-03-28",
        "status": "A",
        "authorized_official_last_name": "BOULWARE",
        "authorized_official_first_name": "STEVEN",
        "authorized_official_title_or_position": "MANAGING MEMBER",
        "authorized_official_telephone_number": "972-428-0900"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SHREVEPORT MANOR SKILLED NURSING AND REHABILITATION",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shreveport, LA

Sources for this page

Verify at the official NPI Registry.