Healthcare Provider Details

I. General information

NPI: 1316106628
Provider Name (Legal Business Name): LAKE END SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 LAKEWOOD DR SUITE A
MORGAN CITY LA
70380-1866
US

IV. Provider business mailing address

PO BOX 1898
MORGAN CITY LA
70381-1898
US

V. Phone/Fax

Practice location:
  • Phone: 985-384-0897
  • Fax: 985-384-0899
Mailing address:
  • Phone: 985-384-0897
  • Fax: 985-384-0899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number201984
License Number StateLA

VIII. Authorized Official

Name: NWOSU O NGOFA
Title or Position: PHYSICIAN
Credential: MD
Phone: 985-384-0897