Basic Information
| Provider Information | |||||||||
| NPI: | 1114342953 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LADY OF THE OAKS RETIREMENT MANOR, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LAFAYETTE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 VETERANS BLVD | ||||||||
| Address2: | |||||||||
| City: | DENHAM SPRINGS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707264722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256646697 | ||||||||
| FaxNumber: | 2256672843 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 BACQUE CRESCENT DR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372320299 | ||||||||
| FaxNumber: | 2256672843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2014 | ||||||||
| LastUpdateDate: | 03/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | DELATTE | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | COMPTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2256646697 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 819 | LA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1510254 | 05 | LA | MEDICAID |