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General NPI Number Information
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NPI Number | 1902009350
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Entity Type | Organization
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Legal Business Name | CHILDRENS CLINIC OF RACELAND LLC
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Dates
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Enumeration Date | 06/05/2007
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Last Update Date | 03/04/2021
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Provider Practice Location Address
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Address Line | 110 ACADIA PARK DR
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City | RACELAND
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State | LA
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Zip | 70394-2618
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Country | US
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Telephone | 985-537-8687
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Fax | 985-537-8976
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Provider Business Mailing Address
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Address Line | 110 ACADIA PARK DR
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City | RACELAND
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State | LA
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Zip | 70394-2618
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Country | US
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Telephone | 985-537-8687
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Fax | 985-537-8976
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Authorized Official
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Title or Position | MEMBER MANAGER
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Name | DR. LUISA CUARIO BACUTA-TAGORDA
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Credential | MD
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Telephone | 985-537-8687
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 08233R
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 08233R
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License Number State | LA
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