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DSH190064AW OUR LADY OF THE LAKE (Active)
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Main Details
Name
OUR LADY OF THE LAKE
Subdivision Name
OLOL STE - SLEEP LAB - SLEEP LAB
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH190064AW
Medicare Provider Number
190064
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
4/12/2019
Participating Start Date
7/1/2019
Participating Approval Date
5/24/2019
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
1125 W Highway 30
Gonzales, LA 70737-5004
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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