MEDICARE: NEW LIFE MEDICAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician		LA

General Provider Information

NPI Number	:	1073848354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW LIFE MEDICAL CENTER

Provider Business Mailing Address
First Line	:	50057 HWY 51 NORTH
Second Line	:
City	:	TICKFAW
State	:	LA
Zip	:	70466
Country	:	US
Telephone Number	:	985-542-7392
Fax Number	:	985-542-7393

Provider Business Practice Location Address
First Line	:	50057 HWY 51 NORTH
Second Line	:
City	:	TICKFAW
State	:	LA
Zip	:	70466
Country	:	US
Telephone Number	:	985-542-7392
Fax Number	:	985-542-7393

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MIRIAM SONG STACEY
Credential	:
Telephone Number	:	985-542-7392

Provider Enumeration Date	:	10/05/2009
Last Update Date	:	10/05/2009

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Directions to “NEW LIFE MEDICAL CENTER ” Practice Location

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