Provider Demographics
NPI:1144711029
Name:LDH FAMILY AFFAIR LLC
Entity type:Organization
Organization Name:LDH FAMILY AFFAIR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EBONY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-715-8726
Mailing Address - Street 1:931 CARMADELLE ST
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-2641
Mailing Address - Country:US
Mailing Address - Phone:504-715-8726
Mailing Address - Fax:504-407-3901
Practice Address - Street 1:931 CARMADELLE ST
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-2641
Practice Address - Country:US
Practice Address - Phone:504-715-8726
Practice Address - Fax:504-407-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA172A00000X172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1598262883Medicaid