=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265971147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. K'S FAMILY MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2017
-----------------------------------------------------
Last Update Date | 07/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2781 S COLUMBIA ST SUITE A
-----------------------------------------------------
City | BOGALUSA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70427-7962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-869-0294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2871 S. COLUMBIA ST STE A
-----------------------------------------------------
City | BOGALUSA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KEISHA HARVEY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 229-829-0294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------