Provider Demographics
NPI:1659552552
Name:ACCEPTANCE KIDMED OF LA, LLC
Entity Type:Organization
Organization Name:ACCEPTANCE KIDMED OF LA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARITA
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:ACKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-928-5362
Mailing Address - Street 1:2156 WOODDALE BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-1403
Mailing Address - Country:US
Mailing Address - Phone:225-928-5362
Mailing Address - Fax:225-928-5363
Practice Address - Street 1:2156 WOODDALE BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-1403
Practice Address - Country:US
Practice Address - Phone:225-928-5362
Practice Address - Fax:225-928-5363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAPPLYINGMedicaid