Provider Demographics
NPI:1790447373
Name:CITYBLOCK MEDICAL PRACTICE LA, LLC
Entity Type:Organization
Organization Name:CITYBLOCK MEDICAL PRACTICE LA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:
Authorized Official - Last Name:MINERVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-321-2528
Mailing Address - Street 1:495 FLATBUSH AVE STE C5
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-3706
Mailing Address - Country:US
Mailing Address - Phone:800-336-1100
Mailing Address - Fax:
Practice Address - Street 1:1042 CAMELLIA BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6680
Practice Address - Country:US
Practice Address - Phone:800-336-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty