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General NPI Number Information
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NPI Number | 1922048735
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Entity Type | Organization
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Legal Business Name | PLAZA ORTHOPEDIC & SPORTS MEDICINE CLINIC LLC
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Dates
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Enumeration Date | 06/08/2006
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Last Update Date | 02/11/2010
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Provider Practice Location Address
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Address Line | 15781 PROFESSIONAL PLZ
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City | HAMMOND
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State | LA
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Zip | 70403-1452
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Country | US
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Telephone | 985-542-1533
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Fax | 985-542-6713
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Provider Business Mailing Address
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Address Line | 15781 PROFESSIONAL PLZ
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City | HAMMOND
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State | LA
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Zip | 70403-1452
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Country | US
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Telephone | 985-542-1533
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Fax | 985-542-6713
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Authorized Official
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Title or Position | PHYSICIAN PARTNER
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Name | JOHN L FAMBROUGH
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Credential | M.D.
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Telephone | 985-542-1533
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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