MEDICARE: LEESVILLE DIAGNOSTIC CENTER LP

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	291U00000X	Clinical Medical Laboratory	21485	LA

General Provider Information

NPI Number	:	1992708499
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEESVILLE DIAGNOSTIC CENTER LP

Provider Business Mailing Address
First Line	:	506 S 6TH ST
Second Line	:	STE C
City	:	LEESVILLE
State	:	LA
Zip	:	71446-4442
Country	:	US
Telephone Number	:	337-239-2992
Fax Number	:	337-392-8543

Provider Business Practice Location Address
First Line	:	506 S 6TH ST
Second Line	:	STE C
City	:	LEESVILLE
State	:	LA
Zip	:	71446-4442
Country	:	US
Telephone Number	:	337-239-2992
Fax Number	:	337-392-8543

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	MR. DAVID LEWIS MILLER
Credential	:
Telephone Number	:	877-892-9813

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	08/22/2020

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