MEDICARE: ETERNITY HEALTH CARE CLINIC, LLC

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	364SA2200X	Adult Health Clinical Nurse Specialist	RN050908 AP03651	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548206436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETERNITY HEALTH CARE CLINIC, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1962
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70602-1962
Country	:	US
Telephone Number	:	337-439-4220
Fax Number	:	337-439-6351

Provider Business Practice Location Address
First Line	:	1432 FOURNET ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-2452
Country	:	US
Telephone Number	:	337-439-4220
Fax Number	:	337-439-6351

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. NONA MARIE LEDAY BRYANT
Credential	:	CNS
Telephone Number	:	337-439-4220

Provider Enumeration Date	:	06/21/2006
Last Update Date	:	08/22/2020

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