Provider Demographics
NPI:1467507913
Name:PELICAN STATE OUTPATIENT CENTER - CARO CLINIC L. L. C.
Entity Type:Organization
Organization Name:PELICAN STATE OUTPATIENT CENTER - CARO CLINIC L. L. C.
Other - Org Name:P. S. O. C. - CARO CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MONTEYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-647-6533
Mailing Address - Street 1:PO BOX 1499
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70707-1499
Mailing Address - Country:US
Mailing Address - Phone:225-647-6533
Mailing Address - Fax:225-644-7533
Practice Address - Street 1:2304 S BURNSIDE AVE STE 2
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4664
Practice Address - Country:US
Practice Address - Phone:225-647-6533
Practice Address - Fax:225-644-7533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CQ23Medicare ID - Type UnspecifiedCLINIC