Healthcare Provider Details

I. General information

NPI: 1467409672
Provider Name (Legal Business Name): LOUISIANA EDOSCOPY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9103 JEFFERSON HWY
BATON ROUGE LA
70809-2440
US

IV. Provider business mailing address

9103 JEFFERSON HWY
BATON ROUGE LA
70809-2440
US

V. Phone/Fax

Practice location:
  • Phone: 225-927-1190
  • Fax: 225-231-8819
Mailing address:
  • Phone: 225-927-1190
  • Fax: 225-231-8819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number46
License Number StateLA

VIII. Authorized Official

Name: DR. CHARLES C. BERGGREEM
Title or Position: DIRECTOR
Credential: M.D.
Phone: 225-927-1190