# COMMUNITY CARE CENTER OF SHREVEPORT SOUTH LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Heritage Manor South
- **Organization subpart:** No

## Provider details

- **NPI number:** 1083662944
- **Authorized official:** MS. TONI PARKINSON (AUTHORIZED REPRESENTATIVE)
- **Authorized official phone:** (601) 709-1408

## Contact information

- **Practice address:** 9712 MANSFIELD RD, SHREVEPORT, LA 71118-4406
- **Practice address phone:** (318) 687-2080
- **Practice address fax:** (318) 688-8103
- **Mailing address:** 9712 MANSFIELD RD, SHREVEPORT, LA 71118-4498
- **Mailing address phone:** (318) 687-2080
- **Mailing address fax:** (318) 688-8103

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 784 | LA | Yes |

## Other

- **Enumeration date:** 05/04/2006
- **Last updated:** 11/30/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1521434 | — | LA |
| 01 | — | 31054 | BLUE CROSS BLUE SHIELD | LA |