MEDICARE: STERLINGTON VILLAGE 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1306089511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STERLINGTON VILLAGE LLC

Provider Business Mailing Address
First Line	:	10374 HIGHWAY 165 N STE D
Second Line	:
City	:	STERLINGTON
State	:	LA
Zip	:	71280-3320
Country	:	US
Telephone Number	:	318-812-2304
Fax Number	:	318-812-2306

Provider Business Practice Location Address
First Line	:	10374 HIGHWAY 165 N STE D
Second Line	:
City	:	STERLINGTON
State	:	LA
Zip	:	71280-3320
Country	:	US
Telephone Number	:	318-812-2304
Fax Number	:	318-812-2306

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	NICOLE HOTARD
Credential	:
Telephone Number	:	318-812-2304

Provider Enumeration Date	:	04/17/2009
Last Update Date	:	09/13/2010

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Directions to “STERLINGTON VILLAGE LLC ” Practice Location

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