Healthcare Provider Details

I. General information

NPI: 1346874732
Provider Name (Legal Business Name): SOUTHEAST FAMILY MEDICAL PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 05/05/2020
Certification Date: 05/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 N MORRISON BLVD STE 125
HAMMOND LA
70401-2242
US

IV. Provider business mailing address

1320 N MORRISON BLVD STE 125
HAMMOND LA
70401-2242
US

V. Phone/Fax

Practice location:
  • Phone: 985-402-3762
  • Fax: 985-256-2591
Mailing address:
  • Phone: 985-402-3762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAZMIN ESCALANTE
Title or Position: NURSE PRACTITIONER
Credential:
Phone: 985-402-3762