Provider Demographics
NPI:1710150446
Name:NORTHLAKE SUPPORTS AND SERVICES CENTER
Entity Type:Organization
Organization Name:NORTHLAKE SUPPORTS AND SERVICES CENTER
Other - Org Name:IVY SPRINGS COMMUNITY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-567-3111
Mailing Address - Street 1:45439 LIVE OAK DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-4526
Mailing Address - Country:US
Mailing Address - Phone:225-567-3111
Mailing Address - Fax:
Practice Address - Street 1:27683 IVY SPRINGS DRIVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:LA
Practice Address - Zip Code:70443
Practice Address - Country:US
Practice Address - Phone:225-567-3111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHLAKE SUPPORTS AND SERVICES CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities