Provider Demographics
NPI:1184839516
Name:LYNN LANE COMMUNITY HOME
Entity Type:Organization
Organization Name:LYNN LANE COMMUNITY HOME
Other - Org Name:HDC LYNN LANE COMMUNITY HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KINDRED
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-567-3111
Mailing Address - Street 1:45439 LIVE OAK DRIVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-9420
Mailing Address - Country:US
Mailing Address - Phone:225-567-3111
Mailing Address - Fax:225-567-3111
Practice Address - Street 1:#3 LYNN LANE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401
Practice Address - Country:US
Practice Address - Phone:985-543-4006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA954320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1712086Medicaid