Healthcare Provider Details

I. General information

NPI: 1073848354
Provider Name (Legal Business Name): NEW LIFE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 10/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50057 HWY 51 NORTH
TICKFAW LA
70466
US

IV. Provider business mailing address

50057 HWY 51 NORTH
TICKFAW LA
70466
US

V. Phone/Fax

Practice location:
  • Phone: 985-542-7392
  • Fax: 985-542-7393
Mailing address:
  • Phone: 985-542-7392
  • Fax: 985-542-7393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. MIRIAM SONG STACEY
Title or Position: OWNER
Credential:
Phone: 985-542-7392