Provider Demographics
NPI:1376590430
Name:LAFOURCHE PARISH HOSPITAL SERVICE DISTRICT NO. 1
Entity Type:Organization
Organization Name:LAFOURCHE PARISH HOSPITAL SERVICE DISTRICT NO. 1
Other - Org Name:LADY OF THE SEA MEDICAL CLINIC - GOLDEN MEADOW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PRACTICE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:TAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAFONT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:985-325-9300
Mailing Address - Street 1:176 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GOLDEN MEADOW
Mailing Address - State:LA
Mailing Address - Zip Code:70357-2938
Mailing Address - Country:US
Mailing Address - Phone:985-475-5200
Mailing Address - Fax:985-475-5664
Practice Address - Street 1:176 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GOLDEN MEADOW
Practice Address - State:LA
Practice Address - Zip Code:70357-2938
Practice Address - Country:US
Practice Address - Phone:985-475-5200
Practice Address - Fax:985-475-5664
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAFOURCHE PARISH HOSPITAL SERVICE DISTRICT 1 LADY OF THE SEA GEN. HOSP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-27
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1459259Medicaid
LA5CH34OtherMEDICARE PART B
LA5CH34OtherMEDICARE PART B