Healthcare Provider Details

I. General information

NPI: 1386867968
Provider Name (Legal Business Name): AGAPE EAR NOSE & THROAT CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 S 5TH ST
LEESVILLE LA
71446-5304
US

IV. Provider business mailing address

1608 S 5TH ST
LEESVILLE LA
71446-5304
US

V. Phone/Fax

Practice location:
  • Phone: 337-392-1000
  • Fax: 337-392-1099
Mailing address:
  • Phone: 337-392-1000
  • Fax: 337-392-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number12272R
License Number StateLA

VIII. Authorized Official

Name: DR. STEVEN KENNETH SEWELL
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 337-392-1000