Provider Demographics
NPI:1386867968
Name:AGAPE EAR NOSE & THROAT CLINIC PC
Entity Type:Organization
Organization Name:AGAPE EAR NOSE & THROAT CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:SEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-392-1000
Mailing Address - Street 1:1608 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-5304
Mailing Address - Country:US
Mailing Address - Phone:337-392-1000
Mailing Address - Fax:337-392-1099
Practice Address - Street 1:1608 S 5TH ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-5304
Practice Address - Country:US
Practice Address - Phone:337-392-1000
Practice Address - Fax:337-392-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12272R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC4958OtherBCBS PROVIDER NUMBER
LA1697664Medicaid
LA5CX36OtherMEDICARE ID