Provider Demographics
NPI:1538284377
Name:AMANDA LACOMB MD PMC
Entity Type:Organization
Organization Name:AMANDA LACOMB MD PMC
Other - Org Name:LACOMB FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LACOMB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-824-8868
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546
Mailing Address - Country:US
Mailing Address - Phone:337-824-8868
Mailing Address - Fax:337-824-8829
Practice Address - Street 1:1322 ELTON RD
Practice Address - Street 2:SUITE F
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546
Practice Address - Country:US
Practice Address - Phone:337-824-8868
Practice Address - Fax:337-824-8829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023135207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1491667Medicaid
LA1446521Medicaid
68142Medicare UPIN