Healthcare Provider Details

I. General information

NPI: 1083088991
Provider Name (Legal Business Name): LAKE AREA MEDICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2015
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 COUNTRY CLUD RD
LAKE CHARLES LA
70605
US

IV. Provider business mailing address

900 COUNTRY CLUB ROAD
LAKE CHARLES LA
70605
US

V. Phone/Fax

Practice location:
  • Phone: 337-532-1829
  • Fax: 337-240-8882
Mailing address:
  • Phone: 337-532-1829
  • Fax: 337-240-8882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number20130793
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number20130793
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number20130793
License Number StateLA

VIII. Authorized Official

Name: MR. MICHAEL JOSEPH BERTRAND JR.
Title or Position: OWNER/MANAGER
Credential: LPN
Phone: 337-532-1829