Provider Demographics
NPI:1164418307
Name:LHI, LLC
Entity Type:Organization
Organization Name:LHI, LLC
Other - Org Name:LAFAYETTE HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WISDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:386-294-3300
Mailing Address - Street 1:512 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAYO
Mailing Address - State:FL
Mailing Address - Zip Code:32066-4136
Mailing Address - Country:US
Mailing Address - Phone:386-294-3300
Mailing Address - Fax:386-294-3301
Practice Address - Street 1:512 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MAYO
Practice Address - State:FL
Practice Address - Zip Code:32066-4136
Practice Address - Country:US
Practice Address - Phone:386-294-3300
Practice Address - Fax:386-294-3301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF130470971314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026448200Medicaid
FL35960908OtherSTATE FACILITY MDS ID NUM
FL105963Medicare Oscar/Certification