Healthcare Provider Details

I. General information

NPI: 1962408781
Provider Name (Legal Business Name): ARK-LA-TEX CHILDRENS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 HOSPITAL DR STE 120
BOSSIER CITY LA
71111-2386
US

IV. Provider business mailing address

2400 HOSPITAL DR STE 120
BOSSIER CITY LA
71111-2386
US

V. Phone/Fax

Practice location:
  • Phone: 318-742-6710
  • Fax: 318-747-5393
Mailing address:
  • Phone: 318-742-6710
  • Fax: 318-747-5393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0404240
License Number StateLA

VIII. Authorized Official

Name: DR. THOMAS LATIOLAIS
Title or Position: PARTNER
Credential: MD
Phone: 318-742-6710