Provider Demographics
NPI:1861420408
Name:LAFAYETTE NURSING HOME LLC
Entity type:Organization
Organization Name:LAFAYETTE NURSING HOME LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:PIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-864-9371
Mailing Address - Street 1:555 B ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:AL
Mailing Address - Zip Code:36862-0109
Mailing Address - Country:US
Mailing Address - Phone:334-864-9371
Mailing Address - Fax:334-864-9981
Practice Address - Street 1:555 B STREET
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:AL
Practice Address - Zip Code:36862-0109
Practice Address - Country:US
Practice Address - Phone:334-864-9371
Practice Address - Fax:334-864-9981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12495314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4752250SMedicaid
AL4752250SMedicaid
AL5151200001Medicare NSC