Healthcare Provider Details

I. General information

NPI: 1033244462
Provider Name (Legal Business Name): LESLIE B FREE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 NELSON ROAD A-4
LAKE CHARLES LA
70605-4196
US

IV. Provider business mailing address

4150 NELSON ROAD BUILDING A SUITE 4
LAKE CHARLES LA
70605-4196
US

V. Phone/Fax

Practice location:
  • Phone: 337-478-2124
  • Fax: 337-477-7616
Mailing address:
  • Phone: 337-478-2124
  • Fax: 337-477-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number01329
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: