MEDICARE: THE LYMPHEDEMA CENTER, 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	174400000X	Specialist

General Provider Information

NPI Number	:	1184746539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE LYMPHEDEMA CENTER, LLC

Provider Business Mailing Address
First Line	:	418 E COLLEGE ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-1704
Country	:	US
Telephone Number	:	337-794-5301
Fax Number	:	337-479-2391

Provider Business Practice Location Address
First Line	:	418 E COLLEGE ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-1704
Country	:	US
Telephone Number	:	337-794-5301
Fax Number	:	337-479-2391

Authorized Official
Title or Position	:	OWNER
Name	:	MS. DIANA MAJESTIC
Credential	:
Telephone Number	:	337-794-5301

Provider Enumeration Date	:	04/05/2007
Last Update Date	:	08/22/2020

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