NPIMap

Organization Active NPI

Seniors Club

  • Custodial Care Facility
  • Shreveport, LA
National Provider Identifier
1417079526
Registry record updated Jun 23, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Custodial Care FacilityTaxonomy code 311Z00000X
License
1114600 Issued in LA
Legal business name
SENIORS CLUB
Practice address
2653 Malcolm St
Shreveport, LA 71108-2720
Phone
(318) 635-0010
Fax
(318) 635-8844
NPI assigned
Apr 6, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 23, 2008

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

Authorized official

Name
Mrs. Karen R. McCoy, RN
Title
Executive Director
Phone
(318) 635-0010

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Custodial Care Facility 311Z00000X 1114600 LA Primary

Addresses

Primary practice location

2653 Malcolm St
Shreveport, LA 71108-2720

Mailing address

2653 Malcolm St
Shreveport, LA 71108-2720
Phone (318) 635-0010

Other identifiers 3

IdentifierTypeStateIssuer
1172596MedicaidLA
1114600MedicaidLA
1560880MedicaidLA

National Provider Directory

National Provider Directory
Tax ID family
Seniors Club3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

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

{
    "created_epoch": "1175817600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1214179200000",
    "number": "1417079526",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2653 MALCOLM ST",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711082720",
            "telephone_number": "318-635-0010",
            "fax_number": "318-635-8844"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2653 MALCOLM ST",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711082720",
            "telephone_number": "318-635-0010",
            "fax_number": "318-635-8844"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SENIORS CLUB",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-06",
        "last_updated": "2008-06-23",
        "status": "A",
        "authorized_official_last_name": "MCCOY",
        "authorized_official_first_name": "KAREN",
        "authorized_official_middle_name": "R.",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "318-635-0010",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "RN"
    },
    "taxonomies": [
        {
            "code": "311Z00000X",
            "taxonomy_group": "",
            "desc": "Custodial Care Facility",
            "state": "LA",
            "license": "1114600",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1172596",
            "state": "LA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1114600",
            "state": "LA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1560880",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Shreveport, LA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 23, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.