Basic Information
| Provider Information | |||||||||
| NPI: | 1780789974 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE CHARLES MEDICAL SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ENDOCRINOLOGY CENTER OF SWLA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1907 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706021907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942919 | ||||||||
| FaxNumber: | 3374942947 | ||||||||
| Practice Location | |||||||||
| Address1: | 2770 3RD AVE STE 345 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374944765 | ||||||||
| FaxNumber: | 3374944766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | USHER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | BRIAN | ||||||||
| AuthorizedOfficialTitleorPosition: | V.P. OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3374943202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | FACHE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 06-00010290 | 01 | LA | OCCUPATIONAL LICENSE | OTHER |