Provider Demographics
NPI:1417085192
Name:MOSS STREET MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:MOSS STREET MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICKIE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:337-232-3371
Mailing Address - Street 1:1417 MOSS ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-3654
Mailing Address - Country:US
Mailing Address - Phone:337-232-3371
Mailing Address - Fax:337-232-3511
Practice Address - Street 1:1417 MOSS ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-3654
Practice Address - Country:US
Practice Address - Phone:337-232-3371
Practice Address - Fax:337-232-3511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10226363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1448397Medicaid
LA5CT77Medicare ID - Type Unspecified