MEDICARE: ALTA ENDOCRINOLOGY CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician

General Provider Information

NPI Number	:	1275269078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTA ENDOCRINOLOGY CLINIC, LLC

Provider Business Mailing Address
First Line	:	4307 BLUEBONNET BLVD STE B
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-9643
Country	:	US
Telephone Number	:	225-437-2582
Fax Number	:

Provider Business Practice Location Address
First Line	:	4307 BLUEBONNET BLVD STE B
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-9643
Country	:	US
Telephone Number	:	225-437-2582
Fax Number	:

Authorized Official
Title or Position	:	MEMBER/MANAGER
Name	:	BRITTANI BREAUX
Credential	:	MD
Telephone Number	:	504-782-1124

Provider Enumeration Date	:	07/26/2022
Last Update Date	:	08/01/2022

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