Healthcare Provider Details

I. General information

NPI: 1447705074
Provider Name (Legal Business Name): SOUTH LOUISIANA PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 PLANK RD
BAKER LA
70714-4911
US

IV. Provider business mailing address

12902 PLANK RD
BAKER LA
70714-4911
US

V. Phone/Fax

Practice location:
  • Phone: 225-218-4816
  • Fax: 225-302-5057
Mailing address:
  • Phone: 225-774-0733
  • Fax: 225-774-7777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberAP06078
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DUSTIN ALLEN LOGUE
Title or Position: OWNER
Credential: ANP
Phone: 225-774-0733