=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578885240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADULT MEDICINE INSTITUTE & DIAGNOSTIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2010
-----------------------------------------------------
Last Update Date | 02/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1937 S BURNSIDE AVE
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70737-4632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-647-1947
-----------------------------------------------------
Fax | 225-644-3943
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1937 S BURNSIDE AVE
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70737-4632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-647-1947
-----------------------------------------------------
Fax | 225-644-3943
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARLOS RUBEN VAZQUEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 225-647-1947
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 022083
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------