Healthcare Provider Details

I. General information

NPI: 1609366053
Provider Name (Legal Business Name): AFFINITY HEALTH GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2516 BROADMOOR BLVD STE 3C1
MONROE LA
71201-2988
US

IV. Provider business mailing address

130 DESIARD ST STE 355
MONROE LA
71201-7363
US

V. Phone/Fax

Practice location:
  • Phone: 318-807-4743
  • Fax: 318-361-2180
Mailing address:
  • Phone: 318-807-7875
  • Fax: 318-812-6603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JANET L JUSTICE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 318-998-3426