Healthcare Provider Details

I. General information

NPI: 1609850270
Provider Name (Legal Business Name): LAKE ARTHUR HEALTH CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 KELLOGG AVE
LAKE ARTHUR LA
70549-4116
US

IV. Provider business mailing address

PO BOX 765
LAKE ARTHUR LA
70549-0765
US

V. Phone/Fax

Practice location:
  • Phone: 337-774-0100
  • Fax: 337-774-0111
Mailing address:
  • Phone: 337-774-0100
  • Fax: 337-774-0111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPO2500
License Number StateLA

VIII. Authorized Official

Name: TINA K MONLEZUN
Title or Position: ADMINISTRATOR
Credential: CFNP
Phone: 337-774-0100