Provider Demographics
NPI:1326081183
Name:LOURDES HEALTH SUPPORT, LLC
Entity Type:Organization
Organization Name:LOURDES HEALTH SUPPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:CARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-458-3600
Mailing Address - Street 1:333 BUTTERNUT DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DE WITT
Mailing Address - State:NY
Mailing Address - Zip Code:13214-2141
Mailing Address - Country:US
Mailing Address - Phone:315-458-3600
Mailing Address - Fax:315-458-2760
Practice Address - Street 1:1155 FRONT ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-1117
Practice Address - Country:US
Practice Address - Phone:607-724-0115
Practice Address - Fax:607-724-0119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA7200000236332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2371222Medicaid
NY2371222Medicaid