Healthcare Provider Details

I. General information

NPI: 1265629166
Provider Name (Legal Business Name): SEASONS HEALTHCARE OF MONROE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1888 HUDSON CIRCLE SUITE 10
MONROE LA
71201
US

IV. Provider business mailing address

1888 HUDSON CIRCLE SUITE 10
MONROE LA
71201
US

V. Phone/Fax

Practice location:
  • Phone: 318-387-2828
  • Fax: 318-387-2827
Mailing address:
  • Phone: 318-387-2828
  • Fax: 318-387-2827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRNO82557
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD.201086
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN075367
License Number StateLA

VIII. Authorized Official

Name: NATHAN WAYNE GOODYEAR
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 318-387-2828