Healthcare Provider Details

I. General information

NPI: 1407901978
Provider Name (Legal Business Name): MEDAMERICA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9305 MAIN ST SUITE D
ZACHARY LA
70791-7441
US

IV. Provider business mailing address

9305 MAIN ST SUITE D
ZACHARY LA
70791-7441
US

V. Phone/Fax

Practice location:
  • Phone: 225-654-4290
  • Fax: 225-654-0102
Mailing address:
  • Phone: 225-654-4290
  • Fax: 225-654-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number1416142
License Number StateLA

VIII. Authorized Official

Name: DEWITT GINN
Title or Position: OWNER OFFICE MANAGER
Credential:
Phone: 225-654-4290