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DSH190064AJ OUR LADY OF THE LAKE REGIONAL MED CTR (Terminated)
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Main Details
Name
OUR LADY OF THE LAKE REGIONAL MED CTR
Subdivision Name
Lake Main Campus-Advanced Imaging
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH190064AJ
Medicare Provider Number
190064
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/15/2018
Participating Start Date
4/1/2018
Participating Approval Date
1/17/2018
Last Recertification Date
9/4/2023
Termination Date
Termination Reason
1/1/2024
Business decision by the Covered Entity
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
4950 ESSEN LANE
BATON ROUGE, LA 70808-3738
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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