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General NPI Number Information
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NPI Number | 1609681345
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Entity Type | Organization
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Legal Business Name | MED ONE HEALTH CLINIC, LLC
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Dates
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Enumeration Date | 02/10/2025
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Last Update Date | 02/12/2025
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Provider Practice Location Address
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Address Line | 349 DOGWOOD SOUTH LN
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City | HAUGHTON
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State | LA
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Zip | 71037-8511
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Country | US
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Telephone | 832-870-8375
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Fax |
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Provider Business Mailing Address
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Address Line | 349 DOGWOOD SOUTH LN
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City | HAUGHTON
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State | LA
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Zip | 71037-8511
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LATRISALA BANKSTON
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Credential | NP
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Telephone | 832-870-8375
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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