Healthcare Provider Details

I. General information

NPI: 1801070065
Provider Name (Legal Business Name): NORTH LAKE SUPPORTS & SERVICES CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30199 JULIA STREET
ALBANY LA
70711
US

IV. Provider business mailing address

45439 LIVE OAK DR
HAMMOND LA
70401-4526
US

V. Phone/Fax

Practice location:
  • Phone: 225-567-3111
  • Fax: 225-567-2017
Mailing address:
  • Phone: 225-567-3111
  • Fax: 225-567-2017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberAPPLIED FOR
License Number StateLA

VIII. Authorized Official

Name: MR. KINDRED HODGE
Title or Position: ADMINISTRATOR
Credential:
Phone: 225-567-3111