Healthcare Provider Details

I. General information

NPI: 1174867402
Provider Name (Legal Business Name): HEARTWISE OF ALEXANDRIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 4TH ST SUITE A
ALEXANDRIA LA
71301-8423
US

IV. Provider business mailing address

301 4TH ST BOX 30134
ALEXANDRIA LA
71301-8423
US

V. Phone/Fax

Practice location:
  • Phone: 318-709-9051
  • Fax: 866-815-4529
Mailing address:
  • Phone: 318-709-9051
  • Fax: 866-815-4529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number018528
License Number StateLA

VIII. Authorized Official

Name: DR. MICHAEL J SCREPETIS
Title or Position: MEMBER
Credential: M.D.
Phone: 318-445-9823