Organization
PEDIATRUST LAKE CHARLES, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LEANN CRAIG (OWNER)
(225) 252-7633
Entity
Organization
Contact information
Practice address
4250 5TH AVE, LAKE CHARLES, LA 70607-3900
(337) 562-7818
Mailing address
6270 SEVENOAKS AVE, BATON ROUGE, LA 70806-7330
(225) 252-7633
(337) 214-2061
Taxonomy
Speciality
Code
Description
License number
State
302F00000X
Exclusive Provider Organization
Primary
2203782281
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2203782281
—
LA
Enumeration date
02/19/2015
Last updated
02/19/2015
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