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DSH190064AE OUR LADY OF THE LAKE (Active)
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Main Details
Name
OUR LADY OF THE LAKE
Subdivision Name
Pediatric Physical Medicine Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH190064AE
Medicare Provider Number
190064
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
4/12/2013
Participating Start Date
7/1/2013
Participating Approval Date
5/21/2013
Last Recertification Date
8/15/2024
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
8415 Goodwood Blvd
Suite 200
Baton Rouge, LA 70806
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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