Provider Demographics
NPI:1912035924
Name:LAKELAND HEALTH CARE HOME AND COMMUNITY BASED WAIVER
Entity Type:Organization
Organization Name:LAKELAND HEALTH CARE HOME AND COMMUNITY BASED WAIVER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
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
Mailing Address - Street 2:SUITE 609
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-3500
Mailing Address - Country:US
Mailing Address - Phone:504-891-8100
Mailing Address - Fax:504-891-8156
Practice Address - Street 1:1206 J W DAVIS DR
Practice Address - Street 2:SUITE 109
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5953
Practice Address - Country:US
Practice Address - Phone:504-891-8100
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:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA 7025251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1011274Medicaid