Provider Demographics
NPI:1962411355
Name:LESLIE LAKES CARE CENTER, LLC
Entity type:Organization
Organization Name:LESLIE LAKES CARE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAWNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-812-2140
Mailing Address - Street 1:1355 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:LA
Mailing Address - Zip Code:71001-3109
Mailing Address - Country:US
Mailing Address - Phone:318-263-9581
Mailing Address - Fax:
Practice Address - Street 1:1355 6TH ST
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:LA
Practice Address - Zip Code:71001-3109
Practice Address - Country:US
Practice Address - Phone:318-263-9581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA859314000000X
332BN1400X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1510653Medicaid
LA5176260001Medicare NSC
LA1510653Medicaid