Basic Information
| Provider Information | |||||||||
| NPI: | 1598245623 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | IMCAL PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4105 KIRKMAN ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706074603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374753100 | ||||||||
| FaxNumber: | 3374753105 | ||||||||
| Practice Location | |||||||||
| Address1: | 4105 KIRKMAN ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706074603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374758022 | ||||||||
| FaxNumber: | 3374758054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2018 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | MICHELE | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 3374758701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NRHCMC | ||||||||
| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.