1982002911 NPI number — AFFINITY HEALTH GROUP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982002911 NPI number — AFFINITY HEALTH GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AFFINITY HEALTH GROUP, LLC
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:
INTERNAL MEDICINE CLINIC
Provider Other Organization Name Type Code:
3
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:
1982002911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 DESIARD ST
Provider Second Line Business Mailing Address:
SUITE 355
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71201-7319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-807-7875
Provider Business Mailing Address Fax Number:
318-812-6603

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2516 BROADMOOR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201-2988
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-998-0353
Provider Business Practice Location Address Fax Number:
318-998-0357
Provider Enumeration Date:
12/08/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BREARD
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT
Authorized Official Telephone Number:
318-361-0900

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  013918 , 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)





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