Provider Demographics
NPI:1306848205
Name:LAKE CHARLES DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:LAKE CHARLES DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-478-9585
Mailing Address - Street 1:PO BOX 4789
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70606-4789
Mailing Address - Country:US
Mailing Address - Phone:337-478-9585
Mailing Address - Fax:337-479-0338
Practice Address - Street 1:1801 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-478-9585
Practice Address - Fax:337-479-0338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1654205Medicaid
192588Medicare ID - Type Unspecified
C18347Medicare UPIN