Provider Demographics
NPI:1801184007
Name:LCMS EAR, NOSE AND THROAT CLINIC OF SOUTHWEST LOUISIANA, LLC
Entity Type:Organization
Organization Name:LCMS EAR, NOSE AND THROAT CLINIC OF SOUTHWEST LOUISIANA, LLC
Other - Org Name:SOUTHWEST LOUISIANA ENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-494-3204
Mailing Address - Street 1:PO BOX 123057 DEPT 3057
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-3057
Mailing Address - Country:US
Mailing Address - Phone:337-480-5595
Mailing Address - Fax:337-480-5596
Practice Address - Street 1:1890 W GAUTHIER RD STE 205
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-7179
Practice Address - Country:US
Practice Address - Phone:337-480-5595
Practice Address - Fax:337-480-5596
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE CHARLES MEDICAL SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-21
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2316664Medicaid