Provider Demographics
NPI:1306025598
Name:THE PLASTIC SURGERY CENTER OF SOUTHWEST LOUISIANA, LLC
Entity Type:Organization
Organization Name:THE PLASTIC SURGERY CENTER OF SOUTHWEST LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:W
Authorized Official - Last Name:COLPITTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-502-8706
Mailing Address - Street 1:215 W PRIEN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8450
Mailing Address - Country:US
Mailing Address - Phone:337-502-8706
Mailing Address - Fax:337-210-1271
Practice Address - Street 1:215 W PRIEN LAKE RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8450
Practice Address - Country:US
Practice Address - Phone:337-502-8706
Practice Address - Fax:337-210-1271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD05703R208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B63303Medicare UPIN