Healthcare Provider Details

I. General information

NPI: 1619000700
Provider Name (Legal Business Name): LIL LUS BOOMING ENTERPRISE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 E SAINT BERNARD HWY STE E
VIOLET LA
70092-3459
US

IV. Provider business mailing address

6201 E SAINT BERNARD HWY STE E
VIOLET LA
70092-3459
US

V. Phone/Fax

Practice location:
  • Phone: 504-682-2440
  • Fax: 504-682-6668
Mailing address:
  • Phone: 504-682-2440
  • Fax: 504-682-6668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberPCA10033
License Number StateLA

VIII. Authorized Official

Name: MRS. BARBARA MANUEL
Title or Position: PRESIDENT
Credential:
Phone: 504-682-2440