Provider Demographics
NPI:1619130002
Name:CENLA LASER CLINIC
Entity Type:Organization
Organization Name:CENLA LASER CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JYOTI
Authorized Official - Middle Name:BAS
Authorized Official - Last Name:GANJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-445-8181
Mailing Address - Street 1:3311 PRESCOTT ROAD
Mailing Address - Street 2:312 CABRINI DOCTORS BUILDING
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301
Mailing Address - Country:US
Mailing Address - Phone:318-445-8181
Mailing Address - Fax:318-445-6575
Practice Address - Street 1:3311 PRESCOTT ROAD
Practice Address - Street 2:312 CABRINI DOCTORS BUILDING
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301
Practice Address - Country:US
Practice Address - Phone:318-445-8181
Practice Address - Fax:318-445-6575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1979627Medicaid
LA377820091OtherBCBS
LA377820091OtherBCBS
LAD05357Medicare UPIN