Provider Demographics
NPI:1891870929
Name:LA BODEGA INC
Entity Type:Organization
Organization Name:LA BODEGA INC
Other - Org Name:AMERACARE HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:R
Authorized Official - Last Name:MIZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-635-6900
Mailing Address - Street 1:327 W 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-3153
Mailing Address - Country:US
Mailing Address - Phone:985-635-6900
Mailing Address - Fax:985-635-6936
Practice Address - Street 1:1579 HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-6374
Practice Address - Country:US
Practice Address - Phone:985-635-6900
Practice Address - Fax:985-635-6936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA922251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1401439Medicaid
LA1401439Medicaid