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General NPI Number Information
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NPI Number | 1336268184
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Entity Type | Organization
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Legal Business Name | MOSS STREET KID MED LLC
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Dates
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Enumeration Date | 03/29/2007
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Last Update Date | 03/19/2025
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Provider Practice Location Address
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Address Line | 1417A MOSS STREET
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City | LAFAYETTE
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State | LA
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Zip | 70501
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Country | US
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Telephone | 337-291-2411
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Fax | 337-291-2412
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Provider Business Mailing Address
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Address Line | 1417A MOSS ST
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City | LAFAYETTE
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State | LA
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Zip | 70501-3654
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Country | US
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Telephone | 337-291-2411
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Fax |
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Authorized Official
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Title or Position | ONWER
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Name | MRS. DESIREE P RICHARD
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Credential | RN
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Telephone | 337-291-2411
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | LA
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