Healthcare Provider Details

I. General information

NPI: 1306174404
Provider Name (Legal Business Name): ALICIA ROSE BALLAS CNIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 STARBRUSH CIR
COVINGTON LA
70433-7208
US

IV. Provider business mailing address

76 STARBRUSH CIR
COVINGTON LA
70433-7208
US

V. Phone/Fax

Practice location:
  • Phone: 985-871-6800
  • Fax: 985-871-0569
Mailing address:
  • Phone: 985-871-6800
  • Fax: 985-871-0569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: