=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619099231
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBRA INEZ WELCH A.B.O.C. AMERICAN BO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2007
-----------------------------------------------------
Last Update Date | 12/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1509 A. NORTH PINE STREET
-----------------------------------------------------
City | DERIDDER
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70634-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-463-9821
-----------------------------------------------------
Fax | 337-463-9821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1509 A. NORTH PINE STREET
-----------------------------------------------------
City | DERIDDER
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70634-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-463-9821
-----------------------------------------------------
Fax | 337-463-9821
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | ABO CERTIFIED 21999
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------