Healthcare Provider Details

I. General information

NPI: 1972147387
Provider Name (Legal Business Name): ENT AND ALLERGY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 WOLF CIR
LAKE CHARLES LA
70605-2348
US

IV. Provider business mailing address

1615 WOLF CIR
LAKE CHARLES LA
70605-2348
US

V. Phone/Fax

Practice location:
  • Phone: 337-312-8681
  • Fax: 337-312-8682
Mailing address:
  • Phone: 337-312-8681
  • Fax: 337-312-8682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: BRAD W LEBERT
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 337-312-4355