MEDICARE: NORMAL LIFE OF LAFAYETTE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1715760	OTHER	LA	VENDOR #
2	877	OTHER	LA	OLD LICENSE NO.

General Provider Information

NPI Number	:	1164792099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORMAL LIFE OF LAFAYETTE, INC.

Provider Business Mailing Address
First Line	:	9901 LINN STATION RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-3808
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8825 GRAHAM DR
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70814-2557
Country	:	US
Telephone Number	:	225-778-5240
Fax Number	:

Authorized Official
Title or Position	:	ASSOC. GEN. COUNSEL/PRIVACY OFFICER
Name	:	MS. DEENA G. OMBRES
Credential	:
Telephone Number	:	502-394-2387

Provider Enumeration Date	:	01/10/2012
Last Update Date	:	01/10/2012

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