Healthcare Provider Details

I. General information

NPI: 1326875931
Provider Name (Legal Business Name): MATS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 CONNELL PARK LN STE A1
BATON ROUGE LA
70806-6534
US

IV. Provider business mailing address

624 CONNELL PARK LN STE A1
BATON ROUGE LA
70806-6534
US

V. Phone/Fax

Practice location:
  • Phone: 225-468-6287
  • Fax: 225-443-4733
Mailing address:
  • Phone: 225-468-6287
  • Fax: 225-251-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KATELYN MELANCON
Title or Position: PROGRAM COORDINATOR
Credential:
Phone: 225-468-6287