Provider Demographics
NPI:1073841417
Name:LAKESIDE HOSPICE, LLC
Entity type:Organization
Organization Name:LAKESIDE HOSPICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-787-7609
Mailing Address - Street 1:8150 N CENTRAL EXPY STE 1800
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-1883
Mailing Address - Country:US
Mailing Address - Phone:469-839-3777
Mailing Address - Fax:469-983-2083
Practice Address - Street 1:42268 VETERANS AVE STE A
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1423
Practice Address - Country:US
Practice Address - Phone:504-456-6011
Practice Address - Fax:504-456-6964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA173251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1580155Medicaid