Provider Demographics
NPI:1497090740
Name:OLOL PONTCHARTRAIN SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:OLOL PONTCHARTRAIN SURGERY CENTER, LLC
Other - Org Name:OUR LADY OF THE LAKE PONTCHARTRAIN SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:4407 HIGHWAY 190 EAST SERVICE RD
Mailing Address - Street 2:STE 200
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4957
Mailing Address - Country:US
Mailing Address - Phone:985-234-9700
Mailing Address - Fax:985-234-9706
Practice Address - Street 1:4407 HIGHWAY 190 EAST SERVICE RD
Practice Address - Street 2:STE 200
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4957
Practice Address - Country:US
Practice Address - Phone:985-234-9700
Practice Address - Fax:985-234-9706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA157261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA290889Medicare PIN
LA19C0001113Medicare Oscar/Certification