Provider Demographics
NPI:1982126520
Name:EXECUTIVE MEDICAL CLINIC OF LAKE CHARLES
Entity Type:Organization
Organization Name:EXECUTIVE MEDICAL CLINIC OF LAKE CHARLES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBRUN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:225-939-0050
Mailing Address - Street 1:765 EAST BAYOU PINES DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5690
Mailing Address - Country:US
Mailing Address - Phone:337-210-1260
Mailing Address - Fax:
Practice Address - Street 1:765 EAST BAYOU PINES DRIVE
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5690
Practice Address - Country:US
Practice Address - Phone:337-210-1260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-14
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAP06496OtherAANP