Provider Demographics
NPI:1033313200
Name:HARBOR HOSPICE OF OAKDALE, LLC
Entity Type:Organization
Organization Name:HARBOR HOSPICE OF OAKDALE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF DATA OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:THIBODAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-813-2332
Mailing Address - Street 1:3406 COLLEGE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-4612
Mailing Address - Country:US
Mailing Address - Phone:409-813-2332
Mailing Address - Fax:409-232-0573
Practice Address - Street 1:209 N 16TH ST
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:LA
Practice Address - Zip Code:71463-2211
Practice Address - Country:US
Practice Address - Phone:318-335-5029
Practice Address - Fax:318-335-5066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PENDING251G00000X
LA19-1656251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA268OtherDHH
LA1031810Medicaid
LA191656Medicare PIN
LA191656Medicare Oscar/Certification