Provider Demographics
NPI:1215580113
Name:MEMORY CLINIC OF LOUISIANA
Entity Type:Organization
Organization Name:MEMORY CLINIC OF LOUISIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-435-7333
Mailing Address - Street 1:PO BOX 1361
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-1361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3326 FRONT ST STE B
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-6418
Practice Address - Country:US
Practice Address - Phone:318-435-7333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty