Healthcare Provider Details

I. General information

NPI: 1710177167
Provider Name (Legal Business Name): SABINE MEDICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 07/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 HIGHLAND DR
MANY LA
71449-3718
US

IV. Provider business mailing address

210 HIGHLAND DR
MANY LA
71449-3718
US

V. Phone/Fax

Practice location:
  • Phone: 318-256-5722
  • Fax: 318-256-5774
Mailing address:
  • Phone: 318-256-5722
  • Fax: 318-256-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13676R
License Number StateLA

VIII. Authorized Official

Name: DR. HUSAM HAIDAR SUKEREK
Title or Position: PRESIDENT/OFFICER
Credential: M.D.
Phone: 318-256-5722