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General NPI Number Information
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NPI Number | 1306899067
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Entity Type | Organization
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Legal Business Name | OUR LADY OF LAKE ASCENSION, LLC
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Dates
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Enumeration Date | 05/17/2006
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Last Update Date | 03/04/2015
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Provider Practice Location Address
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Address Line | 2647 S ST. ELIZABETH BLVD SUITE 100
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City | GONZALES
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State | LA
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Zip | 70737-5021
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Country | US
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Telephone | 225-647-8511
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Fax | 225-644-5213
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Provider Business Mailing Address
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Address Line | 2647 S ST. ELIZABETH BLVD SUITE 100
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City | GONZALES
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State | LA
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Zip | 70737-5021
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Country | US
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Telephone | 225-647-8511
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Fax | 225-644-5213
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOHN F. FRAICHE
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Credential | M.D.
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Telephone | 225-647-8511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 013784
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License Number State | LA
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