1881931152 NPI number — SLAINTE FAMILY CLINIC LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881931152 NPI number — SLAINTE FAMILY CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SLAINTE FAMILY CLINIC 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:
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:
1881931152
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 GATES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71006-4119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-518-8329
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
188 BURT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71006-4900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-965-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/07/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GATES
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
WEAVER
Authorized Official Title or Position:
SOLE OWNER
Authorized Official Telephone Number:
318-518-8329

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP07052 , 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: 1013264878 . This is a "NPI" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 2345419 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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