# OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1972052520
- **Authorized official:** JEFFREY D LIMBOCKER (REGIONAL CFO)
- **Authorized official phone:** (225) 765-8550

## Contact information

- **Practice address:** 1401 N FOSTER DR, BATON ROUGE, LA 70806-1818
- **Practice address phone:** (225) 987-9095
- **Practice address fax:** (225) 987-9096
- **Mailing address:** 5000 HENNESSY BLVD, BATON ROUGE, LA 70808-4375
- **Mailing address phone:** (225) 765-4281
- **Mailing address fax:** (225) 765-5645

## Taxonomy

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

## Other

- **Enumeration date:** 09/23/2016
- **Last updated:** 09/23/2016