Provider Demographics
NPI:1467406926
Name:MEDICAL & OCCUPATIONAL CLINIC OF LAKE CHARLES, L.L.C.
Entity Type:Organization
Organization Name:MEDICAL & OCCUPATIONAL CLINIC OF LAKE CHARLES, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LIWLIWA
Authorized Official - Middle Name:QUITORIANO
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-478-2573
Mailing Address - Street 1:2770 3RD AVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8994
Mailing Address - Country:US
Mailing Address - Phone:337-478-2573
Mailing Address - Fax:337-478-5296
Practice Address - Street 1:2770 3RD AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8994
Practice Address - Country:US
Practice Address - Phone:337-478-2573
Practice Address - Fax:337-478-5296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1444634Medicaid
LA1444634Medicaid