Provider Demographics
NPI:1508482241
Name:PANOPTIC PMR LLC
Entity Type:Organization
Organization Name:PANOPTIC PMR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-377-5228
Mailing Address - Street 1:711 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-6274
Mailing Address - Country:US
Mailing Address - Phone:251-377-5228
Mailing Address - Fax:
Practice Address - Street 1:8088 HAWKS RD
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-6649
Practice Address - Country:US
Practice Address - Phone:251-377-5228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-18
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1508482241OtherBCBS
LA311032OtherLA STATE BOARD OF MEDICAL EXAMINERS
LA1485250Medicaid
LA1508482241OtherAETNA