=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235692211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FDL MEDICAL CONSULTANTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2019
-----------------------------------------------------
Last Update Date | 04/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 265 TIMBERS DR
-----------------------------------------------------
City | SLIDELL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70458-1121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-971-3002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7681
-----------------------------------------------------
City | SLIDELL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70469-7681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TYSHA POWELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-971-3002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------