Healthcare Provider Details

I. General information

NPI: 1902850035
Provider Name (Legal Business Name): AFFINITY HEALTH GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 HWY 132
MANGHAM LA
71259-0219
US

IV. Provider business mailing address

130 DESIARD ST SUITE 355
MONROE LA
71201-7319
US

V. Phone/Fax

Practice location:
  • Phone: 318-248-2807
  • Fax: 318-248-2967
Mailing address:
  • Phone: 318-807-7875
  • Fax: 318-812-9997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MIKE BREARD
Title or Position: VICE PRESIDENT
Credential:
Phone: 318-361-0900