# CLC OF LAKE PROVIDENCE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Lake Providence Subacute Rehab Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1902896657
- **Authorized official:** MR. DOUGLAS M. WRIGHT JR. (MANAGING MEMBER)
- **Authorized official phone:** (662) 680-3148

## Contact information

- **Practice address:** 5976 HIGHWAY 65 N, LAKE PROVIDENCE, LA 71254-5235
- **Practice address phone:** (318) 559-4050
- **Practice address fax:** (318) 559-4052
- **Mailing address:** 5976 HIGHWAY 65 N, LAKE PROVIDENCE, LA 71254-5235
- **Mailing address phone:** (318) 559-4050
- **Mailing address fax:** (318) 559-4052

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 750 | LA | Yes |

## Other

- **Enumeration date:** 10/25/2005
- **Last updated:** 01/28/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1520632 | — | LA |