Provider Demographics
NPI:1003133240
Name:LCP MEDICAL DIRECT LLC
Entity Type:Organization
Organization Name:LCP MEDICAL DIRECT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LAVONNDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:RAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-388-9150
Mailing Address - Street 1:4308 GUION RD STE A
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-3143
Mailing Address - Country:US
Mailing Address - Phone:317-388-9150
Mailing Address - Fax:317-291-6004
Practice Address - Street 1:4308 GUION RD STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-3143
Practice Address - Country:US
Practice Address - Phone:765-749-3791
Practice Address - Fax:317-388-9151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0102114331332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200319370AMedicaid