1639619653 NPI number — LIL BOOS CORNER STORE LLC

Table of content: (NPI 1639619653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639619653 NPI number — LIL BOOS CORNER STORE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIL BOOS CORNER STORE 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:
Provider Other Organization Name Type Code:
6
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:
1639619653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 ST. CLAIR ROAD; SUITE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOYCE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-793-2028
Provider Business Mailing Address Fax Number:
859-594-6639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 ST. CLAIR RD. STE. C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOYCE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-793-2028
Provider Business Practice Location Address Fax Number:
859-594-6639
Provider Enumeration Date:
02/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MADDOX IV
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
318-793-2028

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY.007439-IR , 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: 2204980 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2168053 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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