Healthcare Provider Details

I. General information

NPI: 1679904387
Provider Name (Legal Business Name): HEALTH CLINIC OF MOSS BLUFF, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2013
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 SAM HOUSTON JONES PKWY
MOSS BLUFF LA
70611-5603
US

IV. Provider business mailing address

140 W 4TH ST
DEQUINCY LA
70633-3508
US

V. Phone/Fax

Practice location:
  • Phone: 337-786-5007
  • Fax: 337-786-5009
Mailing address:
  • Phone: 337-786-5007
  • Fax: 337-786-5009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13084R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13083R
License Number StateLA

VIII. Authorized Official

Name: JAGJIT S CHADHA
Title or Position: CEO/OWNER
Credential: MD
Phone: 337-786-5007