Provider Demographics
NPI:1114047735
Name:NWABUEZE NNAMDI INC
Entity Type:Organization
Organization Name:NWABUEZE NNAMDI INC
Other - Org Name:EAST FELICIANA PRIMARY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:NWABUEZE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:225-634-3517
Mailing Address - Street 1:3050 CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:LA
Mailing Address - Zip Code:70748-6135
Mailing Address - Country:US
Mailing Address - Phone:225-634-3517
Mailing Address - Fax:225-635-5057
Practice Address - Street 1:3050 CHARLES DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:LA
Practice Address - Zip Code:70748-6135
Practice Address - Country:US
Practice Address - Phone:225-634-3517
Practice Address - Fax:225-635-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL12712R207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1552232Medicaid
LA2330241Medicaid
LA2330241Medicaid
LA1552232Medicaid
LA5E697CM35Medicare UPIN