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General NPI Number Information
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NPI Number | 1639301732
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Entity Type | Organization
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Legal Business Name | ST. MARYGRACE FAMILY PRACTICE, LLC
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Dates
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Enumeration Date | 08/23/2009
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Last Update Date | 03/18/2011
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Provider Practice Location Address
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Address Line | 1270 ATTAKAPAS DR SUITE 404
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City | OPELOUSAS
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State | LA
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Zip | 70570-6549
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Country | US
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Telephone | 337-678-0918
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Fax | 337-678-0927
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Provider Business Mailing Address
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Address Line | 1270 ATTAKAPAS DR SUITE 404
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City | OPELOUSAS
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State | LA
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Zip | 70570-6549
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Country | US
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Telephone | 337-678-0918
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Fax | 337-678-0927
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Authorized Official
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Title or Position | OWNER / OPERATOR / PHYSICIAN
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Name | DR. ADENIKE A TINUBU
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Credential | MD
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Telephone | 337-678-0918
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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 | 202981
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License Number State | LA
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