Healthcare Provider Details

I. General information

NPI: 1588143556
Provider Name (Legal Business Name): PEDIATRIC CENTER OF MANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S HIGHLAND DR STE A
MANY LA
71449-3719
US

IV. Provider business mailing address

PO BOX 130
NEW LLANO LA
71461-0130
US

V. Phone/Fax

Practice location:
  • Phone: 318-431-5100
  • Fax: 318-808-7007
Mailing address:
  • Phone: 337-239-2207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHELSEA THOMPSON
Title or Position: BUSINESS MANAGER
Credential:
Phone: 337-239-2207