Provider Demographics
NPI:1699971168
Name:OUR LADY OF THE LAKE HOSPITAL, INC.
Entity type:Organization
Organization Name:OUR LADY OF THE LAKE HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICES
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAVIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-765-6565
Mailing Address - Street 1:5000 HENNESSY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4375
Mailing Address - Country:US
Mailing Address - Phone:225-765-7875
Mailing Address - Fax:225-765-9047
Practice Address - Street 1:2401 SILVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808
Practice Address - Country:US
Practice Address - Phone:225-765-7875
Practice Address - Fax:225-765-0947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA38508Medicaid