1811126550 NPI number — FCC OAKDALE

Table of content: (NPI 1811126550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811126550 NPI number — FCC OAKDALE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FCC OAKDALE
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:
1811126550
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5050
Provider Second Line Business Mailing Address:
5050 EAST WHATLEY ROAD
Provider Business Mailing Address City Name:
OAKDALE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71463-5050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-335-4466
Provider Business Mailing Address Fax Number:
318-215-2135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 EAST WHATLEY ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKDALE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71463-5050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-335-4466
Provider Business Practice Location Address Fax Number:
318-215-2135
Provider Enumeration Date:
07/02/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VILLALON
Authorized Official First Name:
SALVADORE
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
318-335-4466

Provider Taxonomy Codes

  • Taxonomy code: 261QP2400X , with the licence number:  A80985 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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