Basic Information
| Provider Information | |||||||||
| NPI: | 1740356856 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORMAL LIFE OF LOUISIANA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9901 LINN STATION RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402233808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008660860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2895 HIGHWAY 190 | ||||||||
| Address2: | SUITES A 1-2 | ||||||||
| City: | MANDEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704713414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856744177 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 12/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | OMBRES | ||||||||
| AuthorizedOfficialFirstName: | DEENA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRIVACY OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5023942387 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 1716421 | 05 | LA | MEDICAID |