Provider Demographics
NPI:1194532341
Name:SOUTHERN GRACE HOSPICE WEST LLC
Entity type:Organization
Organization Name:SOUTHERN GRACE HOSPICE WEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-264-3940
Mailing Address - Street 1:458 HEYMANN BLVD BLDG A
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2627
Mailing Address - Country:US
Mailing Address - Phone:337-366-8505
Mailing Address - Fax:337-366-8565
Practice Address - Street 1:458 HEYMANN BLVD BLDG A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2627
Practice Address - Country:US
Practice Address - Phone:337-366-8505
Practice Address - Fax:337-366-8565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based