Healthcare Provider Details

I. General information

NPI: 1154056208
Provider Name (Legal Business Name): LAKEVIEW TRAUMA AND CRITICAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 JUDGE TANNER BLVD STE 300
COVINGTON LA
70433-7506
US

IV. Provider business mailing address

PO BOX 748630
ATLANTA GA
30374-8630
US

V. Phone/Fax

Practice location:
  • Phone: 985-867-3800
  • Fax:
Mailing address:
  • Phone: 615-373-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN REBOK
Title or Position: GROUP VP/AO
Credential:
Phone: 615-372-5004