Provider Demographics
NPI:1417118175
Name:GROWING UP CHILDREN'S CLINIC LLC
Entity Type:Organization
Organization Name:GROWING UP CHILDREN'S CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAPHNE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-392-2580
Mailing Address - Street 1:145 LAPALCO BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-7149
Mailing Address - Country:US
Mailing Address - Phone:504-392-2580
Mailing Address - Fax:504-392-2527
Practice Address - Street 1:145 LAPALCO BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-7149
Practice Address - Country:US
Practice Address - Phone:504-392-2580
Practice Address - Fax:504-392-2527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023017202C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Single Specialty