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DSH190064BL 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 Children's Hospital - Dialysis - Dialysis
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH190064BL
Medicare Provider Number
190064
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/15/2019
Participating Start Date
10/1/2019
Participating Approval Date
8/6/2019
Last Recertification Date
9/4/2023
Termination Date
Termination Reason
1/1/2024
Other
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
8300 Constantin Blvd
Baton Rouge, LA 70809
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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