Basic Information
| Provider Information | |||||||||
| NPI: | 1144577719 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMPERIAL HEALTH, LLP | ||||||||
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| OtherOrganizationName: | IMPERIAL CALCASIEU MEDICAL GROUP LLP | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 DR MICHAEL DEBAKEY DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706015724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374338400 | ||||||||
| FaxNumber: | 3373126708 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | DEQUINCY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706333508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374014920 | ||||||||
| FaxNumber: | 3373134237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2012 | ||||||||
| LastUpdateDate: | 01/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | RICHARD | ||||||||
| AuthorizedOfficialFirstName: | TONYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3373128291 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.