Provider Demographics
NPI:1669500633
Name:LAKELAND HEALTHCARE HOME & COMMUNITY BASED WAVER
Entity Type:Organization
Organization Name:LAKELAND HEALTHCARE HOME & COMMUNITY BASED WAVER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MORAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-891-8100
Mailing Address - Street 1:3525 PRYTANIA ST STE 609
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-3545
Mailing Address - Country:US
Mailing Address - Phone:504-891-8100
Mailing Address - Fax:504-891-8156
Practice Address - Street 1:105 MEDICAL CENTER DR STE 206
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5538
Practice Address - Country:US
Practice Address - Phone:985-781-7117
Practice Address - Fax:504-891-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA 7025302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPCA 7025Medicaid