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General NPI Number Information
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NPI Number | 1982126520
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Entity Type | Organization
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Legal Business Name | EXECUTIVE MEDICAL CLINIC OF LAKE CHARLES
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Dates
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Enumeration Date | 07/14/2017
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Last Update Date | 09/19/2022
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Provider Practice Location Address
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Address Line | 765 EAST BAYOU PINES DRIVE
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City | LAKE CHARLES
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State | LA
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Zip | 70601-5690
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Country | US
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Telephone | 337-210-1260
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Fax |
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Provider Business Mailing Address
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Address Line | 765 EAST BAYOU PINES DRIVE
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City | LAKE CHARLES
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State | LA
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Zip | 70601-5690
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Country | US
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Telephone | 337-210-1260
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MELISSA LEBRUN
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Credential | DNP
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Telephone | 225-939-0050
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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 | AP06496
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License Number State | LA
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