1104297720 NPI number — SOUTHERN PEDIATRIC CLINIC

Table of content: (NPI 1104297720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104297720 NPI number — SOUTHERN PEDIATRIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN PEDIATRIC CLINIC
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:
1104297720
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 N THOMAS DR
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71107-6539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-221-0277
Provider Business Mailing Address Fax Number:
318-221-3277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 N THOMAS DR
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71107-6539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-221-0277
Provider Business Practice Location Address Fax Number:
318-221-3277
Provider Enumeration Date:
10/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
IMMANUEL
Authorized Official First Name:
STELLA
Authorized Official Middle Name:
GRACE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
318-221-0277

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  MD12866R , 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: 1449237 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com