Basic Information
| Provider Information | |||||||||
| NPI: | 1932601747 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE PRINCE AT HOME LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 LEONARD AVE | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286589649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284658021 | ||||||||
| FaxNumber: | 8284658015 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 ANNA GOODE WAY | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234349236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579235500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2018 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | SUTTON | ||||||||
| AuthorizedOfficialTitleorPosition: | A/R MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8284658021 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKE PRINCE CENTER, INC. | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
No ID Information.