Healthcare Provider Details

I. General information

NPI: 1346092038
Provider Name (Legal Business Name): PEDIATRIC & ADOLESCENT CLINIC OF LOUISIANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 CARTER ST
VIDALIA LA
71373-3115
US

IV. Provider business mailing address

308 HIGHLAND BLVD
NATCHEZ MS
39120-4611
US

V. Phone/Fax

Practice location:
  • Phone: 318-336-7172
  • Fax: 318-336-7176
Mailing address:
  • Phone: 601-442-7676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID TIMM
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 601-442-7676