MEDICARE: LAKE URGENT CARE ASCENSION 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	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1477899656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE URGENT CARE ASCENSION LLC

Provider Business Mailing Address
First Line	:	PO BOX 679641
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75267-9641
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1702 N BURNSIDE AVE
Second Line	:
City	:	GONZALES
State	:	LA
Zip	:	70737-2141
Country	:	US
Telephone Number	:	225-647-4988
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEVE SELLARS
Credential	:
Telephone Number	:	225-214-9353

Provider Enumeration Date	:	12/17/2012
Last Update Date	:	01/24/2023

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