Executive Medical Clinic of Lake Charles

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

AP06496 Issued in LA

Legal business name

EXECUTIVE MEDICAL CLINIC OF LAKE CHARLES

Practice address

765 East Bayou Pines Drive
Lake Charles, LA 70601-5690

Phone

(337) 210-1260

NPI assigned

Jul 14, 2017

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Melissa Lebrun, DNP

Title

President

Phone

(225) 939-0050

Specialties & licenses 1

Addresses

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1499990400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1663545600000",
    "number": "1982126520",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "765 EAST BAYOU PINES DRIVE",
            "city": "LAKE CHARLES",
            "state": "LA",
            "postal_code": "706015690",
            "telephone_number": "337-210-1260"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "765 EAST BAYOU PINES DRIVE",
            "city": "LAKE CHARLES",
            "state": "LA",
            "postal_code": "706015690",
            "telephone_number": "337-210-1260"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EXECUTIVE MEDICAL CLINIC OF LAKE CHARLES",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-07-14",
        "last_updated": "2022-09-19",
        "certification_date": "2022-09-14",
        "status": "A",
        "authorized_official_last_name": "LEBRUN",
        "authorized_official_first_name": "MELISSA",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "225-939-0050",
        "authorized_official_credential": "DNP"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "LA",
            "license": "AP06496",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Family Medicine Physician in Lake Charles, LA
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• Family Medicine Physician in Louisiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 19, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.