Healthcare Provider Details

I. General information

NPI: 1518950732
Provider Name (Legal Business Name): EVANGELINE DIAGNOSTIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 JACK MILLER ROAD, SUITE 1
VILLE PLATTE LA
70586
US

IV. Provider business mailing address

11842 JUSTICE AVENUE
BATON ROUGE LA
70816
US

V. Phone/Fax

Practice location:
  • Phone: 337-363-1465
  • Fax: 337-363-1418
Mailing address:
  • Phone: 225-448-5886
  • Fax: 225-292-5956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number19D0461630
License Number StateLA

VIII. Authorized Official

Name: MR. TERRY S WILKS JR.
Title or Position: OWNER/CEO
Credential:
Phone: 225-448-5886