Healthcare Provider Details

I. General information

NPI: 1992793095
Provider Name (Legal Business Name): ALLEN'S FAMILY PRACTICE CLINIC OF PONCHATOULA, L.L.P.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E OAK ST
PONCHATOULA LA
70454-2619
US

IV. Provider business mailing address

PO BOX 129
PONCHATOULA LA
70454-0129
US

V. Phone/Fax

Practice location:
  • Phone: 985-386-6198
  • Fax: 985-386-6223
Mailing address:
  • Phone: 985-386-6198
  • Fax: 985-386-6223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CATHY L. ALLEN
Title or Position: CLINIC MANAGER
Credential:
Phone: 985-386-6198