1487824256 NPI number — FAMILY FOOT CLINIC, PMC

Table of content: (NPI 1487824256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487824256 NPI number — FAMILY FOOT CLINIC, PMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY FOOT CLINIC, PMC
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:
1487824256
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
335 BAYOU GARDENS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUMA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70364-1434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-868-2425
Provider Business Mailing Address Fax Number:
985-868-2445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 BAYOU GARDENS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUMA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70364-1434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-868-2425
Provider Business Practice Location Address Fax Number:
985-868-2445
Provider Enumeration Date:
03/07/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LASKEY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
504-868-2425

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  PD062R , 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: 1384160 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 23528 . This is a "BCBS OF LA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".