Provider Demographics
NPI:1114201399
Name:OUR LADY OF LAKE ASCENSION, LLC
Entity Type:Organization
Organization Name:OUR LADY OF LAKE ASCENSION, LLC
Other - Org Name:ST ELIZABETH PHYSICIANS DSME PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:FRAICHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-647-8511
Mailing Address - Street 1:2647 S SAINT ELIZABETH BLVD
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-5021
Mailing Address - Country:US
Mailing Address - Phone:225-647-8511
Mailing Address - Fax:
Practice Address - Street 1:2647 S SAINT ELIZABETH BLVD
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5021
Practice Address - Country:US
Practice Address - Phone:225-647-8511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty