Basic Information
| Provider Information | |||||||||
| NPI: | 1942645007 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SWLA CENTER FOR HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 OPELOUSAS STREET | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374399983 | ||||||||
| FaxNumber: | 3374393224 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 N. SIXTH STREET | ||||||||
| Address2: | |||||||||
| City: | OBERLIN | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3376392281 | ||||||||
| FaxNumber: | 3376396199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2013 | ||||||||
| LastUpdateDate: | 05/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | PRICE | ||||||||
| AuthorizedOfficialFirstName: | KOBRINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3374935112 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SWLA CENTER FOR HEALTH SERVICES | ||||||||
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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 | 2351150 | 05 | LA | MEDICAID |