Basic Information
| Provider Information | |||||||||
| NPI: | 1750846663 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 OAK PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374943000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 OAK PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374943000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2019 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | LEBLANC | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | THERESA | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE ANALYST /PROGRAMMER | ||||||||
| AuthorizedOfficialTelephone: | 3374942577 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.