Basic Information
| Provider Information | |||||||||
| NPI: | 1962695361 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE CHARLES MEDICAL SERVICES ORTHOPAEDICS ASSOCIATES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ORTHOPAEDIC SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122165 DEPT 2165 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753122165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942921 | ||||||||
| FaxNumber: | 3374946523 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 OAK PARK BLVD FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374944900 | ||||||||
| FaxNumber: | 3374944797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2007 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON-HATCHER | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3374942094 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKE CHARLES MEDICAL SERVICES INC | ||||||||
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| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1030538 | 05 | LA | MEDICAID | NH8002 | 01 | LA | BCBS | OTHER | DG7217 | 01 | LA | RAILROAD MCR | OTHER |