# EXECUTIVE MEDICAL CLINIC OF LAKE CHARLES

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

## Provider details

- **NPI number:** 1982126520
- **Authorized official:** MELISSA LEBRUN DNP (PRESIDENT)
- **Authorized official phone:** (225) 939-0050

## Contact information

- **Practice address:** 765 EAST BAYOU PINES DRIVE, LAKE CHARLES, LA 70601-5690
- **Practice address phone:** (337) 210-1260
- **Mailing address:** 765 EAST BAYOU PINES DRIVE, LAKE CHARLES, LA 70601-5690
- **Mailing address phone:** (337) 210-1260

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | AP06496 | LA | Yes |

## Other

- **Enumeration date:** 07/14/2017
- **Last updated:** 09/19/2022