1073841417 NPI number — LAKESIDE HOSPICE, LLC

Table of content: (NPI 1073841417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073841417 NPI number — LAKESIDE HOSPICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE HOSPICE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073841417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8150 N CENTRAL EXPY STE 1800
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75206-1883
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-839-3777
Provider Business Mailing Address Fax Number:
469-983-2083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42268 VETERANS AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMMOND
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70403-1423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-456-6011
Provider Business Practice Location Address Fax Number:
504-456-6964
Provider Enumeration Date:
11/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
ANGIE
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSING MANAGER
Authorized Official Telephone Number:
903-787-7609

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  173 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1580155 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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