Basic Information
| Provider Information | |||||||||
| NPI: | 1962411355 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LESLIE LAKES CARE CENTER, LLC | ||||||||
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| OtherOrganizationName: | LESLIE LAKES RETIREMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1355 6TH ST | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710013109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182639581 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1355 6TH ST | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710013109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182639581 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DAWNE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3188122140 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 332BN1400X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies | 314000000X | 859 | LA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1510653 | 05 | LA | MEDICAID |