Provider Demographics
NPI:1619640216
Name:LAKE CHARLES INTRAOPERATIVE NEUROMONITORING, LLC
Entity Type:Organization
Organization Name:LAKE CHARLES INTRAOPERATIVE NEUROMONITORING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:CNIM
Authorized Official - Phone:337-884-4550
Mailing Address - Street 1:701 W SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-2760
Mailing Address - Country:US
Mailing Address - Phone:337-884-4550
Mailing Address - Fax:
Practice Address - Street 1:701 W SCHOOL ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2760
Practice Address - Country:US
Practice Address - Phone:133-788-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty