Provider Demographics
NPI:1063649143
Name:YOUR FAMILY CARE CENTER LLC
Entity Type:Organization
Organization Name:YOUR FAMILY CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDISON
Authorized Official - Middle Name:L
Authorized Official - Last Name:ONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-276-5408
Mailing Address - Street 1:303 BAYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:JEANERETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70544-5801
Mailing Address - Country:US
Mailing Address - Phone:337-276-5408
Mailing Address - Fax:337-276-5452
Practice Address - Street 1:2412 PALMLAND BLVD
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2913
Practice Address - Country:US
Practice Address - Phone:337-519-4740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12332R261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1530301Medicaid
LA12332ROtherMEDICAL LICENSE
LA1598794406OtherPROVIDER NPI
LA1598794406OtherPROVIDER NPI
LA5F696Medicare PIN