Healthcare Provider Details

I. General information

NPI: 1073514493
Provider Name (Legal Business Name): LSUHSC FAMILY PRACTICE CENTER @ LCMH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 OAK PARK BLVD
LAKE CHARLES LA
70601-8849
US

IV. Provider business mailing address

PO BOX 123453, DEPT 3453
DALLAS TX
75312-0001
US

V. Phone/Fax

Practice location:
  • Phone: 337-494-6767
  • Fax: 337-494-6750
Mailing address:
  • Phone: 337-494-2921
  • Fax: 337-494-6523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAWN JOHNSON-HATCHER
Title or Position: CFO
Credential:
Phone: 337-494-2094