Healthcare Provider Details

I. General information

NPI: 1043787302
Provider Name (Legal Business Name): COURTNEY E FOCH LABOVE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 IMPERIAL BLVD BLDG B
LAKE CHARLES LA
70605-5392
US

IV. Provider business mailing address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

V. Phone/Fax

Practice location:
  • Phone: 337-310-3670
  • Fax: 337-421-1408
Mailing address:
  • Phone: 337-312-8528
  • Fax: 337-312-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2694
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: