Healthcare Provider Details

I. General information

NPI: 1699789529
Provider Name (Legal Business Name): ST. LUKE'S DIAGNOSTIC CLINIC OF LAKE CHARLES, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 S RYAN ST
LAKE CHARLES LA
70601-5726
US

IV. Provider business mailing address

643 S RYAN ST
LAKE CHARLES LA
70601-5726
US

V. Phone/Fax

Practice location:
  • Phone: 337-439-2000
  • Fax: 337-439-2025
Mailing address:
  • Phone: 337-439-2000
  • Fax: 337-439-2025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number017896
License Number StateLA

VIII. Authorized Official

Name: DR. BRYAN P BARRILLEAUX
Title or Position: OWNER
Credential: M.D.
Phone: 337-439-2000