Healthcare Provider Details

I. General information

NPI: 1942750526
Provider Name (Legal Business Name): LAG ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 LOUISVILLE AVE
MONROE LA
71201-6027
US

IV. Provider business mailing address

PO BOX 570
LAKE FOREST IL
60045-0570
US

V. Phone/Fax

Practice location:
  • Phone: 318-998-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JAY MASCAGNI
Title or Position: OWNER
Credential: CRNA
Phone: 318-737-7577