Healthcare Provider Details

I. General information

NPI: 1649327107
Provider Name (Legal Business Name): LSAHSC EARL K. LONG MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 N FOSTER DR
BATON ROUGE LA
70806-1818
US

IV. Provider business mailing address

17010 ABITA AVENUE
PRAIRIEVILLE LA
70769
US

V. Phone/Fax

Practice location:
  • Phone: 225-987-9013
  • Fax:
Mailing address:
  • Phone: 225-266-5177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberDPM.PD0105
License Number StateLA

VIII. Authorized Official

Name: CAMILLE ELSBURY
Title or Position: EKL MEDICAL STAFF DEPT. MANAGER
Credential: CPCS
Phone: 225-354-2051