Provider Demographics
NPI:1184605792
Name:COLONNADE ENDOSCOPY CENTER LLC
Entity type:Organization
Organization Name:COLONNADE ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SABRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-439-6226
Mailing Address - Street 1:555 DR MICHAEL DEBAKEY DR STE 102
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5700
Mailing Address - Country:US
Mailing Address - Phone:337-439-6226
Mailing Address - Fax:337-436-8862
Practice Address - Street 1:555 DR MICHAEL DEBAKEY DR STE 102
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-439-6226
Practice Address - Fax:337-436-8862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA099261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1366536Medicaid
11024Medicare ID - Type Unspecified