Provider Demographics
NPI:1073973533
Name:PEDIATRIC GROUP OF ACADIANA LLC
Entity Type:Organization
Organization Name:PEDIATRIC GROUP OF ACADIANA LLC
Other - Org Name:PEDIATRIC GROUP OF ACADIANA & FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JIBRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ATWI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-918-6341
Mailing Address - Street 1:550 WEST VETERANS MEMORIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ERATH
Mailing Address - State:LA
Mailing Address - Zip Code:70533-3430
Mailing Address - Country:US
Mailing Address - Phone:337-918-6341
Mailing Address - Fax:337-918-6346
Practice Address - Street 1:550 WEST VETERANS MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:ERATH
Practice Address - State:LA
Practice Address - Zip Code:70533-3430
Practice Address - Country:US
Practice Address - Phone:337-918-6341
Practice Address - Fax:337-918-6346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health