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General NPI Number Information
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NPI Number | 1235738634
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Entity Type | Organization
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Legal Business Name | LOUISIANA RETINA A PROFESSIONAL MEDICAL CORPORATION
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Dates
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Enumeration Date | 10/19/2020
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Last Update Date | 05/18/2022
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Provider Practice Location Address
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Address Line | 303 VETERANS BLVD STE A
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City | DENHAM SPRINGS
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State | LA
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Zip | 70726-4723
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Country | US
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Telephone | 225-242-9729
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Fax |
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Provider Business Mailing Address
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Address Line | 303 VETERANS BLVD STE A
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City | DENHAM SPRINGS
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State | LA
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Zip | 70726-4723
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Country | US
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Telephone | 225-242-9729
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JORDAN BURNHAM
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Credential | MD
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Telephone | 225-523-7624
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207WX0107X
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Taxonomy Name | Retina Specialist (Ophthalmology) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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