1053365759 NPI number — OUR LADY OF THE LAKE HOSPITAL INC

Table of content: (NPI 1053365759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053365759 NPI number — OUR LADY OF THE LAKE HOSPITAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUR LADY OF THE LAKE HOSPITAL INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHILD ASESSMENT CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053365759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8415 GOODWOOD BLVD
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70806-7851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-765-5727
Provider Business Mailing Address Fax Number:
225-765-9244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8415 GOODWOOD BLVD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70806-7851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-765-8674
Provider Business Practice Location Address Fax Number:
225-765-4062
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STERLING
Authorized Official First Name:
TERRIE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
225-765-6898

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1113069 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06828887 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com