Basic Information
| Provider Information | |||||||||
| NPI: | 1598766941 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIVERSIFIED HEALTH CARE-LAKE CHARLES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE CHARLES CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 ERNEST ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374390336 | ||||||||
| FaxNumber: | 3374940546 | ||||||||
| Practice Location | |||||||||
| Address1: | 2701 ERNEST ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374390336 | ||||||||
| FaxNumber: | 3374940546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 01/26/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GROCE | ||||||||
| AuthorizedOfficialFirstName: | TAMMIE | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | ACCOUNTING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3374390336 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 799 | LA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1510114 | 05 | LA | MEDICAID |