Provider Demographics
NPI:1205230760
Name:PELICAN MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:PELICAN MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LETHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:504-355-7453
Mailing Address - Street 1:54 VETERANS BLVD
Mailing Address - Street 2:
Mailing Address - City:DONALDSONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70346-2450
Mailing Address - Country:US
Mailing Address - Phone:504-355-7453
Mailing Address - Fax:
Practice Address - Street 1:7 LAGI ST
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-8408
Practice Address - Country:US
Practice Address - Phone:504-355-7453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARRT 421207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty