Healthcare Provider Details

I. General information

NPI: 1275194193
Provider Name (Legal Business Name): TOTAL HEALTH CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 GUILBEAU RD
LAFAYETTE LA
70506-8707
US

IV. Provider business mailing address

309 LA RUE FRANCE APT 202
LAFAYETTE LA
70508-3137
US

V. Phone/Fax

Practice location:
  • Phone: 337-428-4263
  • Fax:
Mailing address:
  • Phone: 337-237-8716
  • Fax: 337-237-8716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. KEVIN MCBRIDE
Title or Position: ADMINISTRATOR
Credential:
Phone: 337-237-8716