Provider Demographics
NPI:1083306815
Name:LAKE CHARLES PRIMARY CARE AND WELLNESS
Entity Type:Organization
Organization Name:LAKE CHARLES PRIMARY CARE AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-214-9352
Mailing Address - Street 1:10319 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-2730
Mailing Address - Country:US
Mailing Address - Phone:225-239-7190
Mailing Address - Fax:
Practice Address - Street 1:1905 COUNTRY CLUB RD STE B
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5203
Practice Address - Country:US
Practice Address - Phone:337-990-8002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty