Provider Demographics
NPI:1710495627
Name:MAYFIELD ADVANCED MEDICAL, LLC
Entity Type:Organization
Organization Name:MAYFIELD ADVANCED MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONRAD
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-787-2708
Mailing Address - Street 1:5419 JACKSON ST EXT STE B
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2322
Mailing Address - Country:US
Mailing Address - Phone:318-787-2708
Mailing Address - Fax:318-787-2716
Practice Address - Street 1:5419 JACKSON ST EXT STE B
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2322
Practice Address - Country:US
Practice Address - Phone:318-787-2708
Practice Address - Fax:318-787-2716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty