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General NPI Number Information
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NPI Number | 1811183221
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Entity Type | Organization
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Legal Business Name | WALDHEIM FAMILY PRACTICE CLINIC
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Dates
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Enumeration Date | 09/19/2007
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Last Update Date | 09/19/2007
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Provider Practice Location Address
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Address Line | 77173 HIGHWAY 21
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City | COVINGTON
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State | LA
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Zip | 70435-4011
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Country | US
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Telephone | 985-893-0486
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Fax | 985-893-0349
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Provider Business Mailing Address
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Address Line | 77173 HIGHWAY 21
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City | COVINGTON
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State | LA
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Zip | 70435-4011
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Country | US
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Telephone | 985-893-0486
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Fax | 985-893-0349
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. RICHARD J SANDERS JR.
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Credential | M.D.
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Telephone | 985-893-0486
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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 | 017339
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License Number State | LA
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