Provider Demographics
NPI:1144509068
Name:LIFE HOME LLC
Entity type:Organization
Organization Name:LIFE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAISY
Authorized Official - Middle Name:WASHINGTON
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:MSN RN
Authorized Official - Phone:337-463-3595
Mailing Address - Street 1:736 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-2812
Mailing Address - Country:US
Mailing Address - Phone:337-463-3595
Mailing Address - Fax:337-463-3919
Practice Address - Street 1:736 N PINE ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-2812
Practice Address - Country:US
Practice Address - Phone:337-463-3595
Practice Address - Fax:337-463-3919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12351253Z00000X
LA12217253Z00000X
LA12352253Z00000X
LA10567253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1118036Medicaid
LA1118541Medicaid
LA1134767Medicaid
LA1179299Medicaid
LA1460591Medicaid
LA1466841Medicaid
LA1122734Medicaid