Provider Demographics
NPI:1164749412
Name:LAKE AREA PHYSICIAN SERVICES LLC
Entity Type:Organization
Organization Name:LAKE AREA PHYSICIAN SERVICES LLC
Other - Org Name:LAKE AREA PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:PO BOX 9224
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9224
Mailing Address - Country:US
Mailing Address - Phone:877-848-1457
Mailing Address - Fax:615-465-3017
Practice Address - Street 1:4150 NELSON RD
Practice Address - Street 2:BLDG G
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4148
Practice Address - Country:US
Practice Address - Phone:337-475-4787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE AREA PHYSICIAN SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-27
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1442682Medicaid
LA1442682Medicaid
LA6395420001Medicare NSC