Provider Demographics
NPI:1437172822
Name:LOUISIANA PET/CT IMAGING OF LAKE CHARLES. LLC
Entity Type:Organization
Organization Name:LOUISIANA PET/CT IMAGING OF LAKE CHARLES. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STAGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-952-9141
Mailing Address - Street 1:4241 VETERANS MEMORIAL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-5430
Mailing Address - Country:US
Mailing Address - Phone:888-273-3445
Mailing Address - Fax:504-883-5384
Practice Address - Street 1:831 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-4290
Practice Address - Country:US
Practice Address - Phone:337-433-3001
Practice Address - Fax:337-433-0540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA 10292-L01261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2418459Medicaid
LA5C905Medicare PIN