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General NPI Number Information
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NPI Number | 1487766804
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Entity Type | Organization
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Legal Business Name | SOUTHERN PEDIATRIC CLINIC
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 11/03/2015
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Provider Practice Location Address
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Address Line | 1416 METRO DR
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City | ALEXANDRIA
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State | LA
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Zip | 71301-3424
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Country | US
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Telephone | 318-561-4200
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Fax | 318-561-4205
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Provider Business Mailing Address
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Address Line | 5910 DUBLIN RD
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City | ALEXANDRIA
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State | LA
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Zip | 71303-5234
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Country | US
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Telephone | 318-561-4200
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Fax | 318-561-4205
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Authorized Official
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Title or Position | OWNER
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Name | DR. STELLA IMMANUEL
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Credential | M.D.
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Telephone | 318-730-9760
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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 |
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License Number State | LA
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