Healthcare Provider Details

I. General information

NPI: 1598176653
Provider Name (Legal Business Name): OLIVIA PAIGE BLALOCK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. OLIVIA PAIGE ST. CYR

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 IMPERIAL BLVD BUILDING 2
LAKE CHARLES LA
70605-5362
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: 337-312-8258
  • Fax: 337-312-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2541
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: