NPIMap

Organization Active NPI

Southern Grace Hospice West LLC

  • Community Based Hospice Care Agency
  • Lafayette, LA
National Provider Identifier
1194532341
Registry record updated Dec 11, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Based Hospice Care AgencyTaxonomy code 251G00000X
Legal business name
SOUTHERN GRACE HOSPICE WEST LLC
Practice address
458 Heymann Blvd BLDG a
Lafayette, LA 70503-2627
Phone
(337) 366-8505
Fax
(337) 366-8565
NPI assigned
Dec 11, 2024
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 11, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Timothy A Bergeron
Title
Ceo
Phone
(985) 264-3940

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Based Hospice Care Agency 251G00000X Primary

Addresses

Primary practice location

458 Heymann Blvd BLDG a
Lafayette, LA 70503-2627

Mailing address

458 Heymann Blvd BLDG a
Lafayette, LA 70503-2627
Phone (337) 366-8505

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in LA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20250310003301 LA Part A Provider - Hospice 9739600479 Practice locations: Breaux Bridge, LA

Hospice certification: CCN 191592

Legal name
SOUTHERN GRACE HOSPICE WEST LLC
Doing business as
SOUTHERN GRACE HOSPICE
Certification status
Active
Provider type (POS)
Hospice
Participating since
Oct 6, 2004
Last certification
Sep 23, 2020
Ownership / control type
Proprietary - Other
Organization structure
LLCProprietary
Enrollment address
1442B E Bridge St
Breaux Bridge, LA 70517-3406

Care Compare: Hospice

Medicare Care Compare
Listed as
Southern Grace HospiceCCN 191592
Ownership
For-Profit
Certified
Oct 6, 2004
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory

Locations

1442B E Bridge St
Breaux Bridge, LA 70517
Phone (337) 366-8505

458 Heymann Blvd
Bldg A
Lafayette, LA 70503
Phone (337) 235-8185

Ownership & related parties

All disclosed owners & managing parties 7

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Timothy Bergeron Individual 5% Or Greater Indirect Ownership InterestCeo Dec 4, 2024 100%
Corporate OfficerCeo Dec 4, 2024 100%
Operational/Managerial ControlCeo Dec 4, 2024 100%
Jennifer Boudreaux Individual Corporate OfficerCfo Dec 4, 2024 50%
Nicole Pogue Individual Corporate OfficerCoo Dec 4, 2024 50%
W-2 Managing EmployeeCoo Dec 4, 2024 50%
Operational/Managerial ControlCoo Dec 4, 2024 50%
Southern Grace Management LLC Organization, Abita Springs, LA LLC, Management services company, For-profit Operational/Managerial Control Dec 4, 2024 50%
Ashwin Narayana Individual Contracted Managing EmployeeMD; Jan 10, 2025 50%
Kyle L Caulfield Individual Operational/Managerial ControlTemporary Medical Director Jan 1, 2025 50%
Hospice Holding West LLC Organization, Abita Springs, LA Created for acquisition, LLC, Holding company, For-profit, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Dec 4, 2024 100%

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Affiliated clinicians 10

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1733875200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1733875200000",
    "number": "1194532341",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "458 HEYMANN BLVD BLDG A",
            "city": "LAFAYETTE",
            "state": "LA",
            "postal_code": "705032627",
            "telephone_number": "337-366-8505",
            "fax_number": "337-366-8565"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "458 HEYMANN BLVD BLDG A",
            "city": "LAFAYETTE",
            "state": "LA",
            "postal_code": "705032627",
            "telephone_number": "337-366-8505",
            "fax_number": "337-366-8565"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN GRACE HOSPICE WEST LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-12-11",
        "last_updated": "2024-12-11",
        "certification_date": "2024-12-11",
        "status": "A",
        "authorized_official_last_name": "BERGERON",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "985-264-3940"
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lafayette, LA

Sources for this page

Verify at the official NPI Registry.