# CENTERWELL SENIOR PRIMARY CARE (LA) PC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** CENTERWELL SENIOR PRIMARY CARE (LA) PC
- **Other names:** CenterWell Senior Primary Care - Lake Charles
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1952036998
- **Legal business name:** CENTERWELL SENIOR PRIMARY CARE (LA) PC
- **Authorized official:** ANGIE MARTINEZ (SENIOR CREDENTIALING SPECIALIST)
- **Authorized official phone:** (407) 447-7120

## Contact information

- **Practice address:** 4050 RYAN ST, LAKE CHARLES, LA 70605-2820
- **Practice address phone:** (337) 915-0691
- **Practice address fax:** (877) 706-9899
- **Mailing address:** 4700 MILLENIA BLVD STE 650, ORLANDO, FL 32839-6013
- **Mailing address phone:** (407) 447-7120

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | — |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 207R00000X | Internal Medicine Physician | — | NULL | Yes |
| 207R00000X | Internal Medicine Physician | — | — | Yes |
| 208D00000X | General Practice Physician | — | NULL | — |
| 208D00000X | General Practice Physician | — | — | — |

## Other

- **Enumeration date:** 07/22/2022
- **Last updated:** 08/11/2023