Provider Demographics
NPI:1508833617
Name:LAKESHORE HOSPICE ACQUISITION, LLC
Entity Type:Organization
Organization Name:LAKESHORE HOSPICE ACQUISITION, LLC
Other - Org Name:LAKESHORE HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-549-1877
Mailing Address - Street 1:15781 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1452
Mailing Address - Country:US
Mailing Address - Phone:985-549-1877
Mailing Address - Fax:985-375-1192
Practice Address - Street 1:15781 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1452
Practice Address - Country:US
Practice Address - Phone:985-549-1877
Practice Address - Fax:985-375-1192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203781977251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA19-1588OtherMEDICARE PTAN
LA1580970Medicaid