Provider Demographics
NPI:1497313670
Name:LAKE PROFESSIONALS LLC
Entity Type:Organization
Organization Name:LAKE PROFESSIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLASS
Authorized Official - Middle Name:H
Authorized Official - Last Name:PERRET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-233-1114
Mailing Address - Street 1:PO BOX 53388
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-3388
Mailing Address - Country:US
Mailing Address - Phone:337-233-1114
Mailing Address - Fax:
Practice Address - Street 1:501 W SAINT MARY BLVD STE 210
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4699
Practice Address - Country:US
Practice Address - Phone:337-233-1114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-03
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty