Provider Demographics
NPI:1629405477
Name:SLIDELL FAMILY MEDICAL AND WELLNESS CARE, LLC
Entity Type:Organization
Organization Name:SLIDELL FAMILY MEDICAL AND WELLNESS CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:KREWSKY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:985-326-8011
Mailing Address - Street 1:1375 CORPORATE SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3147
Mailing Address - Country:US
Mailing Address - Phone:985-326-8011
Mailing Address - Fax:985-326-8015
Practice Address - Street 1:1301 BROWNSWITCH RD
Practice Address - Street 2:SUITE C
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-1695
Practice Address - Country:US
Practice Address - Phone:985-326-8011
Practice Address - Fax:985-326-8015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-10
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05069363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA325834Medicare PIN