Healthcare Provider Details

I. General information

NPI: 1497009013
Provider Name (Legal Business Name): THE PEDIATRIC PLACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 01/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18135 E PETROLEUM DR SUITE A
BATON ROUGE LA
70809-6131
US

IV. Provider business mailing address

18135 E PETROLEUM DR SUITE A
BATON ROUGE LA
70809-6131
US

V. Phone/Fax

Practice location:
  • Phone: 225-636-5437
  • Fax: 225-636-5547
Mailing address:
  • Phone: 225-636-5437
  • Fax: 225-636-5547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY B BUSENLENER
Title or Position: MD
Credential:
Phone: 225-636-5437