Healthcare Provider Details

I. General information

NPI: 1750793378
Provider Name (Legal Business Name): AFFINITY HEALTH GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2516 BROADMOOR BLVD
MONROE LA
71201-2988
US

IV. Provider business mailing address

130 DESIARD ST SUITE 355
MONROE LA
71201-7319
US

V. Phone/Fax

Practice location:
  • Phone: 318-812-1125
  • Fax: 318-812-1129
Mailing address:
  • Phone: 318-807-7875
  • Fax: 318-812-6603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number015594
License Number StateLA

VIII. Authorized Official

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