Provider Demographics
NPI:1801070065
Name:NORTH LAKE SUPPORTS & SERVICES CENTER
Entity type:Organization
Organization Name:NORTH LAKE SUPPORTS & SERVICES CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KINDRED
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGE
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:225-567-2017
Practice Address - Street 1:30199 JULIA STREET
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:LA
Practice Address - Zip Code:70711
Practice Address - Country:US
Practice Address - Phone:225-567-3111
Practice Address - Fax:225-567-2017
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA DEPT OF HEALTH & HOSPITALS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAPPLIED FOR320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities