=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740647866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDLEADERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2016
-----------------------------------------------------
Last Update Date | 01/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8369 FLORIDA BLVD SUITE 9
-----------------------------------------------------
City | DENHAM SPRINGS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70726-7862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-243-6997
-----------------------------------------------------
Fax | 225-243-7157
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 78070
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70837-8070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-243-6997
-----------------------------------------------------
Fax | 225-243-7157
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS MANAGER
-----------------------------------------------------
Name | MS. COURTNEY LEIGH ALTAZIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-243-6997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 025596
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------