Healthcare Provider Details

I. General information

NPI: 1750846663
Provider Name (Legal Business Name): MEMORIAL MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 OAK PARK BLVD
LAKE CHARLES LA
70601-8911
US

IV. Provider business mailing address

1701 OAK PARK BLVD
LAKE CHARLES LA
70601-8911
US

V. Phone/Fax

Practice location:
  • Phone: 337-494-3000
  • Fax:
Mailing address:
  • Phone: 337-494-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SARAH THERESA LEBLANC
Title or Position: BUSINESS OFFICE ANALYST /PROGRAMMER
Credential:
Phone: 337-494-2577