Provider Demographics
NPI:1568488849
Name:ZACHARY INTERNAL MEDICINE CLINIC LLC
Entity Type:Organization
Organization Name:ZACHARY INTERNAL MEDICINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VENU
Authorized Official - Middle Name:BABU
Authorized Official - Last Name:KAKARALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-570-2257
Mailing Address - Street 1:1169 HIGHWAY 19 STE B
Mailing Address - Street 2:
Mailing Address - City:SLAUGHTER
Mailing Address - State:LA
Mailing Address - Zip Code:70777-3404
Mailing Address - Country:US
Mailing Address - Phone:225-570-2257
Mailing Address - Fax:225-286-4078
Practice Address - Street 1:1169 HIGHWAY 19 STE B
Practice Address - Street 2:
Practice Address - City:SLAUGHTER
Practice Address - State:LA
Practice Address - Zip Code:70777-3404
Practice Address - Country:US
Practice Address - Phone:225-570-2257
Practice Address - Fax:225-286-4078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1569097Medicaid
LA4A570CA52Medicare ID - Type Unspecified
LA1569097Medicaid