Provider Demographics
NPI:1346223765
Name:CYPRESS AT LAKE PROVIDENCE, LLC
Entity Type:Organization
Organization Name:CYPRESS AT LAKE PROVIDENCE, LLC
Other - Org Name:CYPRESS AT LAKE PROVIDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:COURVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-276-9244
Mailing Address - Street 1:8104 LANES END
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810
Mailing Address - Country:US
Mailing Address - Phone:225-276-9244
Mailing Address - Fax:
Practice Address - Street 1:5976 HIGHWAY 65 N
Practice Address - Street 2:
Practice Address - City:LAKE PROVIDENCE
Practice Address - State:LA
Practice Address - Zip Code:71254-5235
Practice Address - Country:US
Practice Address - Phone:318-559-2248
Practice Address - Fax:318-559-3381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA304314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1513687Medicaid
LA195585Medicare ID - Type Unspecified