MEDICARE: LACIE OURSO KEMP

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1720458961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACIE OURSO KEMP

Provider Business Mailing Address
First Line	:	6750 POYDRAS BAYOU RD
Second Line	:
City	:	ERWINVILLE
State	:	LA
Zip	:	70729-9700
Country	:	US
Telephone Number	:	225-247-5113
Fax Number	:

Provider Business Practice Location Address
First Line	:	1919 HOSPITAL ROAD
Second Line	:	STE A
City	:	NEW ROADS
State	:	LA
Zip	:	70760
Country	:	US
Telephone Number	:	225-638-8449
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2015
Last Update Date	:	06/28/2018

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