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General NPI Number Information
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NPI Number | 1215294830
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Entity Type | Organization
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Legal Business Name | SOUTHCARE MEDICAL LLC
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Dates
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Enumeration Date | 04/19/2012
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 1305 N STATE ST
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City | ABBEVILLE
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State | LA
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Zip | 70510-2825
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Country | US
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Telephone | 337-422-6240
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Fax | 337-422-6241
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Provider Business Mailing Address
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Address Line | 1305 N STATE ST
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City | ABBEVILLE
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State | LA
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Zip | 70510-2825
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Country | US
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Telephone | 337-422-6240
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Fax | 337-422-6241
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | CRISTYANA SUGENG
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Credential | B.A
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Telephone | 337-422-6240
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | MD200292
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | AP07807
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License Number State | LA
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Taxonomy #3
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 2203782387
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License Number State | LA
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