1457808750 NPI number — LLWENDELLYN PAUL

Table of content: LLWENDELLYN PAUL (NPI 1457808750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457808750 NPI number — LLWENDELLYN PAUL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAUL
Provider First Name:
LLWENDELLYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1457808750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1810 CARTER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIDALIA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71373-3115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-336-4797
Provider Business Mailing Address Fax Number:
318-336-4799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 E REYNOLDS DR STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71270-2873
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-254-7050
Provider Business Practice Location Address Fax Number:
318-254-7053
Provider Enumeration Date:
09/02/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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