Basic Information
| Provider Information | |||||||||
| NPI: | 1255441382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSS | ||||||||
| FirstName: | LUCIEN | ||||||||
| MiddleName: | KENNEDY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2770 3RD AVE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374944868 | ||||||||
| FaxNumber: | 3374944870 | ||||||||
| Practice Location | |||||||||
| Address1: | 2770 3RD AVE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374944868 | ||||||||
| FaxNumber: | 3374944870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 04/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 015821 | LA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1341280 | 05 | LA | MEDICAID | 50046C963 | 01 | LA | MEDICARE LEGACY | OTHER |