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General NPI Number Information
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NPI Number | 1114144888
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Entity Type | Organization
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Legal Business Name | CHURCH POINT MEDICAL CLINIC LLC
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Dates
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Enumeration Date | 04/20/2007
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Last Update Date | 06/21/2011
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Provider Practice Location Address
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Address Line | 731 S MAIN ST SUITE A
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City | CHURCH POINT
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State | LA
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Zip | 70525-4109
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Country | US
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Telephone | 337-684-0911
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Fax | 337-684-0912
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Provider Business Mailing Address
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Address Line | 731 S MAIN ST SUITE A
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City | CHURCH POINT
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State | LA
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Zip | 70525-4109
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Country | US
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Telephone | 337-684-0911
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Fax | 337-684-0912
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARCELO POLANCO
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Credential | M.D.
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Telephone | 337-684-0911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | LA023828
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License Number State | LA
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