Provider Demographics
NPI:1659093847
Name:HEALTHY AVENUES MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:HEALTHY AVENUES MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUDIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:504-883-7199
Mailing Address - Street 1:3303 TULANE AVE BLDG 1
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-7186
Mailing Address - Country:US
Mailing Address - Phone:504-377-6628
Mailing Address - Fax:833-907-2256
Practice Address - Street 1:3303 TULANE AVE BLDG 1
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-7186
Practice Address - Country:US
Practice Address - Phone:504-377-6628
Practice Address - Fax:833-907-2256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA20130196OtherLOUISIANA NURSING LICENSE