Provider Demographics
NPI:1518359165
Name:PEDIATRUST LAKE CHARLES, LLC
Entity Type:Organization
Organization Name:PEDIATRUST LAKE CHARLES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-252-7633
Mailing Address - Street 1:6270 SEVENOAKS AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7330
Mailing Address - Country:US
Mailing Address - Phone:225-252-7633
Mailing Address - Fax:337-214-2061
Practice Address - Street 1:4250 5TH AVE
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-3900
Practice Address - Country:US
Practice Address - Phone:337-562-7818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203782281302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2203782281Medicaid