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DSH190064AP OUR LADY OF THE LAKE HOSPITAL, INC. (Terminated)
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Main Details
Name
OUR LADY OF THE LAKE HOSPITAL, INC.
Subdivision Name
OUR LADY OF THE LAKE INFUSION CENTE - Oncology
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH190064AP
Medicare Provider Number
190064
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/15/2019
Participating Start Date
4/1/2019
Participating Approval Date
1/28/2019
Last Recertification Date
8/25/2021
Termination Date
Termination Reason
7/1/2022
Other
Contacts
Authorizing Official
Our Lady of the Lourdes Medical Center
Lowell Edward Stanton, Chief Financial Officer
(337) 470-2147
Primary Contact
Our Lady of the Lake Regional Medical Center
Britney Ross Mellor, Senior Director of Pharmacy
(225) 765-3067
Addresses
Street Address
500 RUE DE LA VIE
SUITE 425
BATON ROUGE, LA 70817-5127
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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