| Southwest Louisiana Independence Center, Inc | |
|
4320 Lake St Lake Charles LA 70605-4310 | |
| (337) 477-7194 | |
| (337) 477-7198 |
| Full Name | Southwest Louisiana Independence Center, Inc |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 4320 Lake St, Lake Charles, Louisiana |
| Authorized Official Name and Position | Randy Dartez (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 3374777194 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Southwest Louisiana Independence Center, Inc 4320 Lake St Lake Charles LA 70605-4310 Ph: (337) 477-7194 | Southwest Louisiana Independence Center, Inc 4320 Lake St Lake Charles LA 70605-4310 Ph: (337) 477-7194 |
| NPI Number | 1700151263 |
|---|---|
| Provider Enumeration Date | 03/16/2012 |
| Last Update Date | 09/06/2023 |
| Certification Date | 09/06/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1700151263 | NPI | - | NPPES |
| 2162187 | Medicaid | LA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | 1156 (Louisiana) | Primary |
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