Provider Demographics
NPI:1538460480
Name:GUILLERMO FAMILY MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:GUILLERMO FAMILY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:J
Authorized Official - Last Name:GUILLERMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-460-7688
Mailing Address - Street 1:301 S WASHINGTON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-4861
Mailing Address - Country:US
Mailing Address - Phone:337-460-7688
Mailing Address - Fax:337-460-7691
Practice Address - Street 1:301 S WASHINGTON ST
Practice Address - Street 2:SUITE A
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4861
Practice Address - Country:US
Practice Address - Phone:337-460-7688
Practice Address - Fax:337-460-7691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.203910207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1005690Medicaid