Healthcare Provider Details

I. General information

NPI: 1124457676
Provider Name (Legal Business Name): PARADISE CHILDREN'S CLINIC OF LOUISIANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4702 MONROE HWY
BALL LA
71405-3944
US

IV. Provider business mailing address

4702 MONROE HWY
BALL LA
71405-3944
US

V. Phone/Fax

Practice location:
  • Phone: 318-641-6113
  • Fax: 318-641-6115
Mailing address:
  • Phone: 318-641-6113
  • Fax: 318-641-6115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY L MASON
Title or Position: OFFICE MANAGER
Credential:
Phone: 318-641-6113