=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194041871
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAST LANE OF ZACHARY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2010
-----------------------------------------------------
Last Update Date | 07/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19900 OLD SCENIC HWY STE H/I
-----------------------------------------------------
City | ZACHARY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70791-7367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-570-2618
-----------------------------------------------------
Fax | 225-570-8539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 427 STE H/I
-----------------------------------------------------
City | ZACHARY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70791-0427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-570-2618
-----------------------------------------------------
Fax | 225-570-8539
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/PARTNER
-----------------------------------------------------
Name | LEONE ELLIOTT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 225-570-2618
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------