Healthcare Provider Details

I. General information

NPI: 1093947905
Provider Name (Legal Business Name): OUR LADY OF THE LAKE HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 04/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 HENNESSY BLVD
BATON ROUGE LA
70808-4375
US

IV. Provider business mailing address

8415 GOODWOOD BLVD STE 105
BATON ROUGE LA
70806-7851
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-7163
  • Fax: 225-765-7164
Mailing address:
  • Phone: 225-765-5727
  • Fax: 225-765-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFERY D. LIMBOCKER JR.
Title or Position: CFO
Credential:
Phone: 225-765-6306