Provider Demographics
NPI:1881641405
Name:COASTAL PAIN CARE LAKE CHARLES, LLC
Entity Type:Organization
Organization Name:COASTAL PAIN CARE LAKE CHARLES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:WIDCAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-477-9019
Mailing Address - Street 1:PO BOX 4840
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70606-4840
Mailing Address - Country:US
Mailing Address - Phone:337-477-9019
Mailing Address - Fax:337-478-1290
Practice Address - Street 1:215 W PRIEN LAKE RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8450
Practice Address - Country:US
Practice Address - Phone:337-477-9019
Practice Address - Fax:337-478-1290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0168242081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CR23Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER