Provider Demographics
NPI: | 1609267897 |
---|---|
Name: | AFFINITY HEALTH GROUP, LLC |
Entity Type: | Organization |
Organization Name: | AFFINITY HEALTH GROUP, LLC |
Other - Org Name: | OLIVER ROAD FAMILY PRACTICE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | DIRECTOR OF OPERATIONS |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JANET |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | JUSTICE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 318-807-7875 |
Mailing Address - Street 1: | 130 DESIARD ST |
Mailing Address - Street 2: | SUITE 355 |
Mailing Address - City: | MONROE |
Mailing Address - State: | LA |
Mailing Address - Zip Code: | 71201-7319 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 318-387-7875 |
Mailing Address - Fax: | 318-812-6603 |
Practice Address - Street 1: | 920 OLIVER RD # M |
Practice Address - Street 2: | |
Practice Address - City: | MONROE |
Practice Address - State: | LA |
Practice Address - Zip Code: | 71201-5702 |
Practice Address - Country: | US |
Practice Address - Phone: | 318-329-9202 |
Practice Address - Fax: | 318-329-1258 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2015-02-10 |
Last Update Date: | 2021-12-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty |