Basic Information
| Provider Information | |||||||||
| NPI: | 1255540662 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LHCG-XII, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EUNICE EXTENDED CARE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 W PINHOOK RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372331307 | ||||||||
| FaxNumber: | 3372335764 | ||||||||
| Practice Location | |||||||||
| Address1: | 3879 HIGHWAY 190 | ||||||||
| Address2: | |||||||||
| City: | EUNICE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705357900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375460024 | ||||||||
| FaxNumber: | 3375460703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 04/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | INDEST | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND COO | ||||||||
| AuthorizedOfficialTelephone: | 3372331307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LHCG-XII, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 607-B | LA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1700665 | 05 | LA | MEDICAID |