Healthcare Provider Details

I. General information

NPI: 1356767305
Provider Name (Legal Business Name): NEW HAVEN MHT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 DOCTOR MICHAEL DEBAKEY DR SUITE 120
LAKE CHARLES LA
70601-5887
US

IV. Provider business mailing address

1515 HERITAGE DRIVE SUITE 110
MCKINNEY TX
75069-3379
US

V. Phone/Fax

Practice location:
  • Phone: 855-860-2109
  • Fax:
Mailing address:
  • Phone: 972-616-4702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.202004
License Number StateLA

VIII. Authorized Official

Name: ANTHONY ADEOSUN
Title or Position: OWNER
Credential: M.D.
Phone: 855-860-2109