1780827717 NPI number — ASSURED MEDICAL GROUP, INC

Table of content: (NPI 1780827717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780827717 NPI number — ASSURED MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASSURED MEDICAL GROUP, INC
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:
1780827717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
139 JAMES COMEAUX RD STE B
Provider Second Line Business Mailing Address:
NO 575
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-3376
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-654-5871
Provider Business Mailing Address Fax Number:
122-520-8141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 AMERICAN LEGION DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAYNE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70578-5826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-654-5871
Provider Business Practice Location Address Fax Number:
225-208-1415
Provider Enumeration Date:
04/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EWING
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
337-654-5871

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  PCA 15206 , 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: 70 EPSDT , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03 CHILDREN CHOICE , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89 SIL WAIVER , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 73 SOCIAL WORKER , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82 PCA WAIVER , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06 NOW PROFESSIONAL , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 24 PERSONAL CARE SER , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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