Provider Demographics
NPI:1639301732
Name:ST. MARYGRACE FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:ST. MARYGRACE FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / OPERATOR / PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ADENIKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:TINUBU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-678-0918
Mailing Address - Street 1:1270 ATTAKAPAS DR
Mailing Address - Street 2:SUITE 404
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-6549
Mailing Address - Country:US
Mailing Address - Phone:337-678-0918
Mailing Address - Fax:337-678-0927
Practice Address - Street 1:1270 ATTAKAPAS DR
Practice Address - Street 2:SUITE 404
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6549
Practice Address - Country:US
Practice Address - Phone:337-678-0918
Practice Address - Fax:337-678-0927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-23
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202981207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1306055652OtherDR'S NPI
LA4507245Medicaid
LA1306055652OtherDR'S NPI