Provider Demographics
NPI:1649564824
Name:LTP MEDICAL MOBILE, INC.
Entity Type:Organization
Organization Name:LTP MEDICAL MOBILE, INC.
Other - Org Name:THE HEALTH HUT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-513-1212
Mailing Address - Street 1:310 WEST MISSISSIPPI AVE.
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-9541
Mailing Address - Country:US
Mailing Address - Phone:318-513-1212
Mailing Address - Fax:318-513-7673
Practice Address - Street 1:310 WEST MISSISSIPPI AVE.
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-9541
Practice Address - Country:US
Practice Address - Phone:318-513-1212
Practice Address - Fax:318-513-7673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-05
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2428438Medicaid
LA1885436Medicaid
BL2571950OtherDEA
1801966973OtherNPI