Healthcare Provider Details

I. General information

NPI: 1184605792
Provider Name (Legal Business Name): COLONNADE ENDOSCOPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 DR MICHAEL DEBAKEY DR STE 102
LAKE CHARLES LA
70601
US

IV. Provider business mailing address

555 DR MICHAEL DEBAKEY DR STE 102
LAKE CHARLES LA
70601-5700
US

V. Phone/Fax

Practice location:
  • Phone: 337-439-6226
  • Fax: 337-436-8862
Mailing address:
  • Phone: 337-439-6226
  • Fax: 337-436-8862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number099
License Number StateLA

VIII. Authorized Official

Name: SABRA BROWN MOORE
Title or Position: ADMINISTRATOR
Credential:
Phone: 337-439-6226