Healthcare Provider Details

I. General information

NPI: 1710078449
Provider Name (Legal Business Name): JEFFERSON FAMILY MEDICAL CENTER ,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 LEE DR. SUITE B
BATON ROUGE LA
70808-1601
US

IV. Provider business mailing address

330 LEE DR. SUITE B
BATON ROUGE LA
70808-1601
US

V. Phone/Fax

Practice location:
  • Phone: 225-926-4780
  • Fax: 225-926-4783
Mailing address:
  • Phone: 225-926-4780
  • Fax: 225-926-4783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number12387R
License Number StateLA

VIII. Authorized Official

Name: BRIAN ALLAN HEISE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 225-926-4780