Basic Information
| Provider Information | |||||||||
| NPI: | 1124360854 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LC OF LOUISIANA HEALTHCARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1009 MAIN ST | ||||||||
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| City: | BASTROP | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786023840 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 OAK PARK BLVD | ||||||||
| Address2: | LAKE CHARLES MEMORIAL HEALTH SYSTEM | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374943000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2013 | ||||||||
| LastUpdateDate: | 03/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | CANDELARIO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE MBR | ||||||||
| AuthorizedOfficialTelephone: | 2102150990 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.