Provider Demographics
NPI:1437664943
Name:PRIMARY CARE AT HOME OF LOUISIANA IV, LLC
Entity Type:Organization
Organization Name:PRIMARY CARE AT HOME OF LOUISIANA IV, LLC
Other - Org Name:PRIMARY CARE AT HOME OF KENNER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:STELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-233-1307
Mailing Address - Street 1:PO BOX 51266
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-1266
Mailing Address - Country:US
Mailing Address - Phone:337-233-1307
Mailing Address - Fax:337-233-5764
Practice Address - Street 1:200 W ESPLANADE AVE STE 601
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2475
Practice Address - Country:US
Practice Address - Phone:504-252-3305
Practice Address - Fax:504-208-3249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty