Healthcare Provider Details

I. General information

NPI: 1407808405
Provider Name (Legal Business Name): LAKE CHARLES MEMORIAL HEART AND VASCULAR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 OAK PARK BLVD FL 2
LAKE CHARLES LA
70601-8990
US

IV. Provider business mailing address

PO BOX 122152, DEPT 2152 DEPT 2152
DALLAS TX
75312-2152
US

V. Phone/Fax

Practice location:
  • Phone: 337-494-3278
  • Fax: 337-494-3240
Mailing address:
  • Phone: 337-494-2921
  • Fax: 337-494-6523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number StateLA

VIII. Authorized Official

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