Provider Demographics
NPI:1013900760
Name:DEER CREEK IMAGING CENTER
Entity Type:Organization
Organization Name:DEER CREEK IMAGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-238-0167
Mailing Address - Street 1:301 W FERTITTA BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4665
Mailing Address - Country:US
Mailing Address - Phone:337-392-1363
Mailing Address - Fax:
Practice Address - Street 1:301 W FERTITTA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4665
Practice Address - Country:US
Practice Address - Phone:337-392-1363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1449253Medicaid
LA1449253Medicaid
LA=========0OtherBLUE CROSS