MEDICARE: CALCASIEU URGENT CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1376901694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALCASIEU URGENT CARE LLC

Provider Business Mailing Address
First Line	:	242 SAM HOUSTON JONES PKWY
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70611-5603
Country	:	US
Telephone Number	:	337-905-4000
Fax Number	:	337-905-4003

Provider Business Practice Location Address
First Line	:	242 SAM HOUSTON JONES PKWY
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70611-5603
Country	:	US
Telephone Number	:	337-905-4000
Fax Number	:	337-905-4003

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	SYDNI CLEMMONS
Credential	:
Telephone Number	:	901-351-1791

Provider Enumeration Date	:	02/01/2016
Last Update Date	:	04/06/2021

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