Healthcare Provider Details

I. General information

NPI: 1962174342
Provider Name (Legal Business Name): SWLA NEONATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2903 1ST AVE
LAKE CHARLES LA
70601-8809
US

IV. Provider business mailing address

PO BOX 13047
LAKE CHARLES LA
70612-3047
US

V. Phone/Fax

Practice location:
  • Phone: 337-478-6480
  • Fax:
Mailing address:
  • Phone: 337-794-1724
  • Fax: 337-855-1829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY L TALBERT
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 337-794-1585