Provider Demographics
NPI:1972052520
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:REGIONAL CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LIMBOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-765-8550
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:225-765-4281
Mailing Address - Fax:225-765-5645
Practice Address - Street 1:1401 N FOSTER DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-1818
Practice Address - Country:US
Practice Address - Phone:225-987-9095
Practice Address - Fax:225-987-9096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care