Provider Demographics
NPI:1073545869
Name:SIXTEEN LAC INC
Entity Type:Organization
Organization Name:SIXTEEN LAC INC
Other - Org Name:SERENITY HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICAL
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-241-2244
Mailing Address - Street 1:4600 OCEAN DR APT 405
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-2542
Mailing Address - Country:US
Mailing Address - Phone:361-241-2244
Mailing Address - Fax:361-241-7220
Practice Address - Street 1:4600 OCEAN DR APT 405
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-2542
Practice Address - Country:US
Practice Address - Phone:361-241-2244
Practice Address - Fax:361-241-7220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX012489251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX012489OtherTDADS LICENSE
TX351823501Medicaid