Provider Demographics
NPI:1386009264
Name:EALY, LADARIUS D
Entity Type:Individual
Prefix:
First Name:LADARIUS
Middle Name:D
Last Name:EALY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 KYLE ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-3686
Mailing Address - Country:US
Mailing Address - Phone:318-461-0790
Mailing Address - Fax:
Practice Address - Street 1:102 KYLE ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-3686
Practice Address - Country:US
Practice Address - Phone:318-461-0790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA101YM0800XMedicaid