MEDICARE: PRIMARY CARE AT HOME OF LOUISIANA IV, 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	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1437664943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY CARE AT HOME OF LOUISIANA IV, LLC

Provider Business Mailing Address
First Line	:	PO BOX 51266
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70505-1266
Country	:	US
Telephone Number	:	337-233-1307
Fax Number	:	337-233-5764

Provider Business Practice Location Address
First Line	:	200 W ESPLANADE AVE STE 601
Second Line	:
City	:	KENNER
State	:	LA
Zip	:	70065-2475
Country	:	US
Telephone Number	:	504-252-3305
Fax Number	:	504-208-3249

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DONALD D. STELLY
Credential	:
Telephone Number	:	337-233-1307

Provider Enumeration Date	:	12/06/2017
Last Update Date	:	12/06/2017

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