Provider Demographics
NPI:1346092038
Name:PEDIATRIC & ADOLESCENT CLINIC OF LOUISIANA LLC
Entity Type:Organization
Organization Name:PEDIATRIC & ADOLESCENT CLINIC OF LOUISIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TIMM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-442-7676
Mailing Address - Street 1:308 HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4611
Mailing Address - Country:US
Mailing Address - Phone:601-442-7676
Mailing Address - Fax:
Practice Address - Street 1:1806 CARTER ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3115
Practice Address - Country:US
Practice Address - Phone:318-336-7172
Practice Address - Fax:318-336-7176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health