Provider Demographics
NPI:1700978806
Name:J & R LAGRANGE, LLC
Entity Type:Organization
Organization Name:J & R LAGRANGE, LLC
Other - Org Name:THE RICHWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-272-6682
Mailing Address - Street 1:1012 RICHWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-8930
Mailing Address - Country:US
Mailing Address - Phone:502-222-3186
Mailing Address - Fax:502-222-6535
Practice Address - Street 1:1012 RICHWOOD WAY
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-8930
Practice Address - Country:US
Practice Address - Phone:502-222-3186
Practice Address - Fax:502-222-6535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X, 235Z00000X, 332BN1400X
KY100818314000000X, 332B00000X, 332BP3500X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing FacilityGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility SuppliesGroup - Multi-Specialty
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral NutritionGroup - Multi-Specialty
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000054853OtherANTHEM BC/BS
KY2702411000OtherPASSPORT ADVANTAGE
KY12503413Medicaid
KY2702411000OtherPASSPORT ADVANTAGE
KY1208770001Medicare NSC