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General NPI Number Information
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NPI Number | 1538460480
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Entity Type | Organization
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Legal Business Name | GUILLERMO FAMILY MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 11/09/2010
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Last Update Date | 11/09/2010
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Provider Practice Location Address
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Address Line | 301 S WASHINGTON ST SUITE A
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City | DERIDDER
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State | LA
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Zip | 70634-4861
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Country | US
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Telephone | 337-460-7688
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Fax | 337-460-7691
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Provider Business Mailing Address
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Address Line | 301 S WASHINGTON ST SUITE A
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City | DERIDDER
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State | LA
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Zip | 70634-4861
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Country | US
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Telephone | 337-460-7688
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Fax | 337-460-7691
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | DR. ANDRES J GUILLERMO
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Credential | M.D.
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Telephone | 337-460-7688
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD.203910
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License Number State | LA
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