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DSH190064AL OUR LADY OF THE LAKE (Active)
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Main Details
Name
OUR LADY OF THE LAKE
Subdivision Name
OUR LADY OF THE LAKE WOUND AND HYPE - Wound Care
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH190064AL
Medicare Provider Number
190064
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
7/16/2018
Participating Start Date
10/1/2018
Participating Approval Date
7/19/2018
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
7301 HENNESSY BLVD
Suite 103
BATON ROUGE, LA 70808-4793
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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