Provider Demographics
NPI:1205296340
Name:OUR LADY OF THE ANGELS CLINIC
Entity type:Organization
Organization Name:OUR LADY OF THE ANGELS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARKET PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:SPICER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-730-6700
Mailing Address - Street 1:433 PLAZA ST
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-3729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1416 GOBBLER HEAD DR
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-6091
Practice Address - Country:US
Practice Address - Phone:985-730-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF THE ANGELS HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-02
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty