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DSH190064CK OUR LADY OF THE LAKE (Approved)
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Main Details
Name
OUR LADY OF THE LAKE
Subdivision Name
Lake Main Campus-OP Diabetes Management - Diabetes
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH190064CK
Medicare Provider Number
190064
Outpatient Facility Provider Number
Additional Details
Current Program Status
Approved
Registration Date
4/3/2025
Participating Start Date
7/1/2025
Participating Approval Date
4/7/2025
Last Recertification Date
Contacts
Authorizing Official
FMOLHS
Jennifer Clowers, Chief Financial Officer
(225) 765-8550
Primary Contact
OUR LADY OF THE LAKE REGIONAL MED CTR
Thomas Greene, Senior Director of Pharmacy, Baton Rouge Market
(225) 765-8786
Addresses
Street Address
2041 Silverside Dr
Baton Rouge, LA 70808
Billing Address
FMOLHS Accounts Payable
P.O. Box 83880
Baton Rouge, LA 70884
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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