Provider Demographics
NPI:1114057148
Name:PLASTIC SURGERY ASSOCIATES OF SOUTHWEST LOUISIANA, LLC
Entity Type:Organization
Organization Name:PLASTIC SURGERY ASSOCIATES OF SOUTHWEST LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-497-1958
Mailing Address - Street 1:PO BOX 2085
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-2085
Mailing Address - Country:US
Mailing Address - Phone:337-497-1958
Mailing Address - Fax:337-433-4024
Practice Address - Street 1:4150 NELSON RD
Practice Address - Street 2:BLDG D STE 2B
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4148
Practice Address - Country:US
Practice Address - Phone:337-497-1958
Practice Address - Fax:337-433-4024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1330663Medicaid
LA1978671Medicaid
LA1330663Medicaid
LA5CC64Medicare ID - Type Unspecified
LA1978671Medicaid