Basic Information
| Provider Information | |||||||||
| NPI: | 1427466614 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SYNERGY CARE SOUTHEAST, LLC | ||||||||
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| OtherOrganizationName: | SYNERGY CARE SOUTHEAST LLC - TEXAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706014393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373108500 | ||||||||
| FaxNumber: | 8882413028 | ||||||||
| Practice Location | |||||||||
| Address1: | 127 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706014393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373108500 | ||||||||
| FaxNumber: | 8882413028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2014 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | BROUSSARD | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3373108500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.