Provider Demographics
NPI:1235912502
Name:OUR LADY OF THE LAKE PHYSICIAN GROUP LLC
Entity Type:Organization
Organization Name:OUR LADY OF THE LAKE PHYSICIAN GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JAMY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-526-0121
Mailing Address - Street 1:PO BOX 677957
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-7957
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:
Practice Address - Street 1:1805 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-1919
Practice Address - Country:US
Practice Address - Phone:225-923-3420
Practice Address - Fax:225-922-9316
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF THE LAKE PHYSICIAN GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)