Healthcare Provider Details

I. General information

NPI: 1821156878
Provider Name (Legal Business Name): SLIDELL FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 GAUSE BLVD SUITE 380
SLIDELL LA
70458-2951
US

IV. Provider business mailing address

PO BOX 160
SLIDELL LA
70459-0160
US

V. Phone/Fax

Practice location:
  • Phone: 985-641-8191
  • Fax: 985-641-9812
Mailing address:
  • Phone: 985-641-8191
  • Fax: 985-641-9812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD 06533R
License Number StateLA

VIII. Authorized Official

Name: DR. CUONG VAN LE
Title or Position: OWNER
Credential: M.D.
Phone: 985-641-8191