Provider Demographics
NPI:1518950732
Name:EVANGELINE DIAGNOSTIC CENTER LLC
Entity type:Organization
Organization Name:EVANGELINE DIAGNOSTIC CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:225-448-5886
Mailing Address - Street 1:11842 JUSTICE AVENUE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816
Mailing Address - Country:US
Mailing Address - Phone:225-448-5886
Mailing Address - Fax:225-292-5956
Practice Address - Street 1:504 JACK MILLER ROAD, SUITE 1
Practice Address - Street 2:
Practice Address - City:VILLE PLATTE
Practice Address - State:LA
Practice Address - Zip Code:70586
Practice Address - Country:US
Practice Address - Phone:337-363-1465
Practice Address - Fax:337-363-1418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19D0461630291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA19D0461630OtherCLIA
LA36930OtherBLUE CROSS BLUE SHIELD
LA1369942Medicaid
LA36930OtherBLUE CROSS BLUE SHIELD