Healthcare Provider Details

I. General information

NPI: 1548287584
Provider Name (Legal Business Name): CHILDREN'S CLINIC OF SOUTHWEST LOUISIANA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2903 1ST AVE
LAKE CHARLES LA
70601-8809
US

IV. Provider business mailing address

2903 1ST AVE
LAKE CHARLES LA
70601-8809
US

V. Phone/Fax

Practice location:
  • Phone: 337-478-6480
  • Fax: 337-474-9637
Mailing address:
  • Phone: 337-478-6480
  • Fax: 337-474-9637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRUCE MICHAEL THOMPSON
Title or Position: PRESIDENT/CEO
Credential: M.D.
Phone: 337-478-6480