Healthcare Provider Details

I. General information

NPI: 1376527143
Provider Name (Legal Business Name): PREMIER PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 METRO DR BLDG L
ALEXANDRIA LA
71301-3448
US

IV. Provider business mailing address

PO BOX 12610
ALEXANDRIA LA
71315-2610
US

V. Phone/Fax

Practice location:
  • Phone: 318-767-1543
  • Fax: 318-767-1110
Mailing address:
  • Phone: 318-767-1543
  • Fax: 318-767-1110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD021955
License Number StateLA

VIII. Authorized Official

Name: JOHN L CLARK JR.
Title or Position: OWNER
Credential: MD
Phone: 318-767-1543