Provider Demographics
NPI:1407808405
Name:LAKE CHARLES MEMORIAL HEART AND VASCULAR CENTER
Entity type:Organization
Organization Name:LAKE CHARLES MEMORIAL HEART AND VASCULAR CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON-HATCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-494-2094
Mailing Address - Street 1:PO BOX 122152, DEPT 2152 DEPT 2152
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2152
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:1717 OAK PARK BLVD FL 2
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8990
Practice Address - Country:US
Practice Address - Phone:337-494-3278
Practice Address - Fax:337-494-3240
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST LOUISIANA HEALTH CARE SYSTEM, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-17
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207RC0000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LACE9693OtherRAILROAD MEDICARE
LA1948098Medicaid
TX078516401Medicaid
TX078516401Medicaid