Basic Information
| Provider Information | |||||||||
| NPI: | 1922424357 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OCEANS ROG LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3905 HEDGCOXE RD UNIT 250249 | ||||||||
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| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750250840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724640022 | ||||||||
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| Practice Location | |||||||||
| Address1: | 302 W MCNEESE ST | ||||||||
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| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706055604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374080797 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2014 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | ARCHER | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9724640022 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 357171 | 01 | LA | PTAN | OTHER | 2396714 | 05 | LA | MEDICAID | 357168 | 01 | LA | PTAN | OTHER |