1912150814 NPI number — BELLATOR HEALTH CARE MANAGEMENT, LLC

Table of content: LYDIA ANN CHWASTIAK MD (NPI 1972592731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912150814 NPI number — BELLATOR HEALTH CARE MANAGEMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELLATOR HEALTH CARE MANAGEMENT, LLC
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:
Provider Other Organization Name Type Code:
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:
1912150814
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10615 JEFFERSON HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70809-7230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-769-2449
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 YORKTOWN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71303-3621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-561-7778
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
225-769-2449

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1126 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 19D0864226 . This is a "CLIA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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