Provider Demographics
NPI:1578333639
Name:PEACOCK PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:PEACOCK PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APRN, FNP-BS
Authorized Official - Phone:318-510-3943
Mailing Address - Street 1:426 GOLDSBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8346
Mailing Address - Country:US
Mailing Address - Phone:318-510-3943
Mailing Address - Fax:888-366-9528
Practice Address - Street 1:426 GOLDSBERRY CIR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8346
Practice Address - Country:US
Practice Address - Phone:318-510-3943
Practice Address - Fax:888-366-9528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1810843Medicaid