Provider Demographics
NPI:1235234162
Name:PAIGE ONE MEDICAL, LLC
Entity Type:Organization
Organization Name:PAIGE ONE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:NREMT-P, BGS
Authorized Official - Phone:225-791-1700
Mailing Address - Street 1:8369 FLORIDA BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-7862
Mailing Address - Country:US
Mailing Address - Phone:225-791-1700
Mailing Address - Fax:225-791-1750
Practice Address - Street 1:8369 FLORIDA BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-7862
Practice Address - Country:US
Practice Address - Phone:225-791-1700
Practice Address - Fax:225-791-1750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAP0854549174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CV66Medicare PIN