Healthcare Provider Details

I. General information

NPI: 1073852075
Provider Name (Legal Business Name): SYNERGY CARE SOUTHEAST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2013
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 W BROAD ST
LAKE CHARLES LA
70601-4291
US

IV. Provider business mailing address

127 W BROAD ST
LAKE CHARLES LA
70601-4291
US

V. Phone/Fax

Practice location:
  • Phone: 337-310-8500
  • Fax: 888-241-3028
Mailing address:
  • Phone: 337-310-8500
  • Fax: 888-241-3028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. TODD BROUSSARD
Title or Position: CONTROLLER
Credential:
Phone: 337-310-8500