Provider Demographics
NPI:1487796710
Name:OUR LADY OF THE LAKE HOSPITAL INC
Entity type:Organization
Organization Name:OUR LADY OF THE LAKE HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ARBONEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-369-3600
Mailing Address - Street 1:8415 GOODWOOD BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806
Mailing Address - Country:US
Mailing Address - Phone:225-765-4361
Mailing Address - Fax:225-765-4062
Practice Address - Street 1:135 HWY 402
Practice Address - Street 2:
Practice Address - City:NAPOLEONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70390
Practice Address - Country:US
Practice Address - Phone:985-369-3600
Practice Address - Fax:985-369-4236
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF THE LAKE HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-13
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA451207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1948217Medicaid
LA=========OtherTAX ID NUMBER
LA5F988Medicare ID - Type Unspecified