Provider Demographics
NPI:1801994074
Name:LETOURNEAU LIFELIKE ORTHOTICS & PROSTHETICS OF LOUISIANA, INC.
Entity type:Organization
Organization Name:LETOURNEAU LIFELIKE ORTHOTICS & PROSTHETICS OF LOUISIANA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:GINGRAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-397-2165
Mailing Address - Street 1:PO BOX 24128
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-4128
Mailing Address - Country:US
Mailing Address - Phone:336-397-2165
Mailing Address - Fax:336-397-2167
Practice Address - Street 1:3113 LAKE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8337
Practice Address - Country:US
Practice Address - Phone:337-477-9102
Practice Address - Fax:337-477-9104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1651681Medicaid
LA1651681Medicaid