Healthcare Provider Details

I. General information

NPI: 1265417141
Provider Name (Legal Business Name): PEDIATRIC CLINIC OF WEST MONROE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 CONTEMPO AVE
WEST MONROE LA
71291-5312
US

IV. Provider business mailing address

104 CONTEMPO AVE
WEST MONROE LA
71291-5312
US

V. Phone/Fax

Practice location:
  • Phone: 318-329-8181
  • Fax: 318-329-8183
Mailing address:
  • Phone: 318-329-8181
  • Fax: 318-329-8183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM MALMAY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 318-329-8181