Provider Demographics
NPI:1588062079
Name:OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC
Entity type:Organization
Organization Name:OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIMBOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-765-8551
Mailing Address - Street 1:2051 SILVERSIDE DR
Mailing Address - Street 2:SUITE 260
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-9005
Mailing Address - Country:US
Mailing Address - Phone:225-490-8808
Mailing Address - Fax:225-765-9687
Practice Address - Street 1:5439 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-1712
Practice Address - Country:US
Practice Address - Phone:225-358-4853
Practice Address - Fax:225-358-2350
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care