Healthcare Provider Details

I. General information

NPI: 1184791287
Provider Name (Legal Business Name): AFFINITY HEALTH GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SAINT JOHN ST
MONROE LA
71201-7322
US

IV. Provider business mailing address

130 DESIARD ST STE 355
MONROE LA
71201-7319
US

V. Phone/Fax

Practice location:
  • Phone: 318-387-5681
  • Fax: 318-322-9957
Mailing address:
  • Phone: 318-807-7875
  • Fax: 318-812-9997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP04747
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD016846
License Number StateLA

VIII. Authorized Official

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