1184052789 NPI number — CENTRAL LA. FAMILY HEALTH AND WELLNESS CENTER

Table of content: (NPI 1184052789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184052789 NPI number — CENTRAL LA. FAMILY HEALTH AND WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL LA. FAMILY HEALTH AND WELLNESS CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184052789
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3516 NORTH BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71301-3613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-441-2220
Provider Business Mailing Address Fax Number:
318-441-2205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3516 NORTH BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71301-3613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-441-2220
Provider Business Practice Location Address Fax Number:
318-441-2205
Provider Enumeration Date:
10/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ELKINS
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
318-441-2220

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  MD13101R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1366452807 . This is a "NPPES" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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