Healthcare Provider Details

I. General information

NPI: 1760545867
Provider Name (Legal Business Name): SHALOM CLINIC FOR CHILDREN APMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 BIENVILLE ST
NATCHITOCHES LA
71457-5748
US

IV. Provider business mailing address

405 BIENVILLE ST
NATCHITOCHES LA
71457-5748
US

V. Phone/Fax

Practice location:
  • Phone: 318-356-7211
  • Fax: 318-356-7226
Mailing address:
  • Phone: 318-356-7211
  • Fax: 318-356-7226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200937
License Number StateLA

VIII. Authorized Official

Name: DR. OLUSEGUN ADEDAMOLA ADELEYE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 318-356-7211