Provider Demographics
NPI:1467675462
Name:THE FAMILY CARE CENTER OF SOUTHWEST LOUISIANA, LLC
Entity Type:Organization
Organization Name:THE FAMILY CARE CENTER OF SOUTHWEST LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-439-1484
Mailing Address - Street 1:2345 SAMPSON ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:LA
Mailing Address - Zip Code:70669-2711
Mailing Address - Country:US
Mailing Address - Phone:337-439-1484
Mailing Address - Fax:337-430-0927
Practice Address - Street 1:2345 SAMPSON ST
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:LA
Practice Address - Zip Code:70669-2711
Practice Address - Country:US
Practice Address - Phone:337-439-1484
Practice Address - Fax:337-430-0927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1021571Medicaid
LA1021571Medicaid