Healthcare Provider Details

I. General information

NPI: 1497313670
Provider Name (Legal Business Name): LAKE PROFESSIONALS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W SAINT MARY BLVD STE 210
LAFAYETTE LA
70506-4699
US

IV. Provider business mailing address

PO BOX 53388
LAFAYETTE LA
70505-3388
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-1114
  • Fax:
Mailing address:
  • Phone: 337-233-1114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUGLASS H PERRET
Title or Position: CEO
Credential:
Phone: 337-233-1114