Provider Demographics
NPI:1669669495
Name:JEFFERSON LINER JR & DOROTHY LEWIS PTRS
Entity Type:Organization
Organization Name:JEFFERSON LINER JR & DOROTHY LEWIS PTRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:H
Authorized Official - Last Name:FORREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-542-1364
Mailing Address - Street 1:PO BOX 2308
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-2308
Mailing Address - Country:US
Mailing Address - Phone:985-542-1364
Mailing Address - Fax:985-542-8679
Practice Address - Street 1:120 N CATE ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-3357
Practice Address - Country:US
Practice Address - Phone:985-542-1364
Practice Address - Fax:985-542-8679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1309559Medicaid
=========0OtherBLUE CROSS BLUE SHIELD
5DF06Medicare PIN