=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144105107
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GULF COAST PSYCHIATRY SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2025
-----------------------------------------------------
Last Update Date | 08/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4045 ERNEST ST
-----------------------------------------------------
City | LAKE CHARLES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70605-3421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-439-8111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3014 DAUPHINE ST STE A
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70117-6755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-439-8111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ZACHARY RYDER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 337-439-8111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------