Healthcare Provider Details

I. General information

NPI: 1124360854
Provider Name (Legal Business Name): LC OF LOUISIANA HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 OAK PARK BLVD LAKE CHARLES MEMORIAL HEALTH SYSTEM
LAKE CHARLES LA
70601
US

IV. Provider business mailing address

1009 MAIN ST
BASTROP TX
78602-3840
US

V. Phone/Fax

Practice location:
  • Phone: 337-494-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL CANDELARIO
Title or Position: SOLE MBR
Credential:
Phone: 210-215-0990