Provider Demographics
NPI:1194095745
Name:NORMAL LIFE OF LAFAYETTE, INC.
Entity type:Organization
Organization Name:NORMAL LIFE OF LAFAYETTE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOC. GEN. COUNSEL/PRIVACY OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEENA
Authorized Official - Middle Name:G
Authorized Official - Last Name:OMBRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-394-2387
Mailing Address - Street 1:9901 LINN STATION RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5051 RAYMOND LABAUVE RD
Practice Address - Street 2:
Practice Address - City:BRUSLY
Practice Address - State:LA
Practice Address - Zip Code:70719-2337
Practice Address - Country:US
Practice Address - Phone:225-778-5175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1717304OtherVENDOR #
LA880OtherOLD LICENSE NO.