Basic Information
| Provider Information | |||||||||
| NPI: | 1568001014 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SWLA CENTER FOR HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SWLACENTER FOR HEALTH SERVICES- SOWELA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 OPELOUSAS ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706012641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374399983 | ||||||||
| FaxNumber: | 3374398898 | ||||||||
| Practice Location | |||||||||
| Address1: | 3820 SENATOR J. BENNETT JOHNSTON AVE | ||||||||
| Address2: | CHARLESTON BLDG 8 | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374399983 | ||||||||
| FaxNumber: | 3374398898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2020 | ||||||||
| LastUpdateDate: | 08/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | BOUDREAUX | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 3377699451 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 2531581 | 05 | LA | MEDICAID |