# OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1588062079
- **Legal business name:** OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC
- **Authorized official:** MR. JEFFREY LIMBOCKER (CFO)
- **Authorized official phone:** (225) 765-8551

## Contact information

- **Practice address:** 5439 AIRLINE HWY, BATON ROUGE, LA 70805-1712
- **Practice address phone:** (225) 358-4853
- **Practice address fax:** (225) 358-2350
- **Mailing address:** 2051 SILVERSIDE DR, SUITE 260, BATON ROUGE, LA 70808-9005
- **Mailing address phone:** (225) 490-8808
- **Mailing address fax:** (225) 765-9687

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QU0200X | Urgent Care Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 12/15/2014
- **Last updated:** 12/15/2014