MEDICARE: LAKE AREA MEDICAL SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251J00000X	Nursing Care Agency	20130793	LA
2	376K00000X	Nurse's Aide	20130793	LA
3	164W00000X	Licensed Practical Nurse	20130793	LA

General Provider Information

NPI Number	:	1083088991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE AREA MEDICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	900 COUNTRY CLUB ROAD
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605
Country	:	US
Telephone Number	:	337-532-1829
Fax Number	:	337-240-8882

Provider Business Practice Location Address
First Line	:	2420 COUNTRY CLUD RD
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605
Country	:	US
Telephone Number	:	337-532-1829
Fax Number	:	337-240-8882

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	MR. MICHAEL JOSEPH BERTRAND JR.
Credential	:	LPN
Telephone Number	:	337-532-1829

Provider Enumeration Date	:	11/17/2015
Last Update Date	:	11/17/2015

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