Healthcare Provider Details

I. General information

NPI: 1821513508
Provider Name (Legal Business Name): FOREVER KID PEDIATRIC PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3321 FLORIDA AVE
KENNER LA
70065
US

IV. Provider business mailing address

3321 FLORIDA AVE
KENNER LA
70065-3680
US

V. Phone/Fax

Practice location:
  • Phone: 504-461-2224
  • Fax: 504-461-2226
Mailing address:
  • Phone: 504-461-2224
  • Fax: 504-461-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number07446R
License Number StateLA

VIII. Authorized Official

Name: EDITH LUZ LINARES
Title or Position: OWNER
Credential: MD
Phone: 504-461-2224