Provider Demographics
NPI:1548206436
Name:ETERNITY HEALTH CARE CLINIC, LLC
Entity Type:Organization
Organization Name:ETERNITY HEALTH CARE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NONA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LEDAY BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:CNS
Authorized Official - Phone:337-439-4220
Mailing Address - Street 1:PO BOX 1962
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-1962
Mailing Address - Country:US
Mailing Address - Phone:337-439-4220
Mailing Address - Fax:337-439-6351
Practice Address - Street 1:1432 FOURNET ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-2452
Practice Address - Country:US
Practice Address - Phone:337-439-4220
Practice Address - Fax:337-439-6351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN050908 AP03651364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1106798Medicaid
LA4B662Medicare ID - Type UnspecifiedMEDICARE PROVIDER
LAP20647Medicare UPIN