1972645216 NPI number — OUR LADY OF THE LAKE REGIONAL MEDICA

Table of content: (NPI 1972645216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972645216 NPI number — OUR LADY OF THE LAKE REGIONAL MEDICA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUR LADY OF THE LAKE REGIONAL MEDICA
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:
6
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:
1972645216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2011
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:
SUITE 105
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-413-4361
Provider Business Mailing Address Fax Number:
225-765-4062

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7777 HENNESSY BLVD
Provider Second Line Business Practice Location Address:
PLAZA 1 SUITE 406
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-765-3456
Provider Business Practice Location Address Fax Number:
225-765-1899
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
TAMARA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BUSINESS SERVICES
Authorized Official Telephone Number:
225-765-4251

Provider Taxonomy Codes

  • Taxonomy code: 2080P0214X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1445584 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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