Basic Information
| Provider Information | |||||||||
| NPI: | 1336383033 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SWLA CENTER FOR HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SWLA CENTER FOR H. S. - CROWLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 OPELOUSAS STREET | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706012641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377835519 | ||||||||
| FaxNumber: | 3373101161 | ||||||||
| Practice Location | |||||||||
| Address1: | 526 CROWLEY RAYNE HWY | ||||||||
| Address2: | |||||||||
| City: | CROWLEY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705268209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377835519 | ||||||||
| FaxNumber: | 3377835521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2009 | ||||||||
| LastUpdateDate: | 05/13/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRICE | ||||||||
| AuthorizedOfficialFirstName: | KOBRINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3374935112 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SWLA CENTER FOR HEALTH SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | EI1843 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1882828 | 05 | LA | MEDICAID |