Healthcare Provider Details

I. General information

NPI: 1902009350
Provider Name (Legal Business Name): CHILDRENS CLINIC OF RACELAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 ACADIA PARK DR
RACELAND LA
70394-2618
US

IV. Provider business mailing address

110 ACADIA PARK DR
RACELAND LA
70394-2618
US

V. Phone/Fax

Practice location:
  • Phone: 985-537-8687
  • Fax: 985-537-8976
Mailing address:
  • Phone: 985-537-8687
  • Fax: 985-537-8976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number08233R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number08233R
License Number StateLA

VIII. Authorized Official

Name: DR. LUISA CUARIO BACUTA-TAGORDA
Title or Position: MEMBER MANAGER
Credential: MD
Phone: 985-537-8687