Healthcare Provider Details

I. General information

NPI: 1689739971
Provider Name (Legal Business Name): CHILDRENS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 STOREHOUSE LANE SUITE B
DESTREHAN LA
70047
US

IV. Provider business mailing address

3 STOREHOUSE LANE SUITE B
DESTREHAN LA
70047
US

V. Phone/Fax

Practice location:
  • Phone: 985-764-6556
  • Fax: 985-764-6526
Mailing address:
  • Phone: 985-764-6556
  • Fax: 985-764-6526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MUHAMMAD SHUJA
Title or Position: PART OWNER
Credential: MD
Phone: 985-764-6556