Provider Demographics
NPI:1073848354
Name:NEW LIFE MEDICAL CENTER
Entity Type:Organization
Organization Name:NEW LIFE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:SONG
Authorized Official - Last Name:STACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-542-7392
Mailing Address - Street 1:50057 HWY 51 NORTH
Mailing Address - Street 2:
Mailing Address - City:TICKFAW
Mailing Address - State:LA
Mailing Address - Zip Code:70466
Mailing Address - Country:US
Mailing Address - Phone:985-542-7392
Mailing Address - Fax:985-542-7393
Practice Address - Street 1:50057 HWY 51 NORTH
Practice Address - Street 2:
Practice Address - City:TICKFAW
Practice Address - State:LA
Practice Address - Zip Code:70466
Practice Address - Country:US
Practice Address - Phone:985-542-7392
Practice Address - Fax:985-542-7393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty