Provider Demographics
NPI:1619919271
Name:OUR LAKE OF THE LAKE HEAD AND NECK CE
Entity Type:Organization
Organization Name:OUR LAKE OF THE LAKE HEAD AND NECK CE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-765-4251
Mailing Address - Street 1:8415 GOODWOOD BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7851
Mailing Address - Country:US
Mailing Address - Phone:225-765-4361
Mailing Address - Fax:225-765-4062
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:STE 409
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-1765
Practice Address - Fax:225-765-1768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty