Healthcare Provider Details

I. General information

NPI: 1992122642
Provider Name (Legal Business Name): SOUTHERN PODIATRY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2014
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

537 KENTUCKY AVE STE B
BOGALUSA LA
70427-3913
US

IV. Provider business mailing address

537 KENTUCKY AVE STE B
BOGALUSA LA
70427-3913
US

V. Phone/Fax

Practice location:
  • Phone: 985-215-5618
  • Fax: 985-732-0100
Mailing address:
  • Phone: 985-215-5618
  • Fax: 985-732-0100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License NumberDPM.200052
License Number StateLA

VIII. Authorized Official

Name: MR. DAVID P ALLEN
Title or Position: OWNER
Credential: D.P.M.
Phone: 985-215-5618