Provider Demographics
NPI:1255846994
Name:LILLY PAD HOME HEALTH
Entity Type:Organization
Organization Name:LILLY PAD HOME HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-410-5836
Mailing Address - Street 1:1507 HARDY ST STE 201
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-4978
Mailing Address - Country:US
Mailing Address - Phone:601-410-5836
Mailing Address - Fax:888-449-9560
Practice Address - Street 1:11 N WATER ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36602-3809
Practice Address - Country:US
Practice Address - Phone:601-410-5836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06732371Medicaid