Provider Demographics
NPI:1790801454
Name:LANNAN FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:LANNAN FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:LANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-527-2491
Mailing Address - Street 1:5204 LAPAIX DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-9369
Mailing Address - Country:US
Mailing Address - Phone:337-527-2491
Mailing Address - Fax:337-528-2749
Practice Address - Street 1:622 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5052
Practice Address - Country:US
Practice Address - Phone:337-527-2491
Practice Address - Fax:337-528-2749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10386R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1999857Medicaid
LA436895832COtherBLUE CROSS BLUE SHIELD LA
LA5U849CN19Medicare PIN
LA436895832COtherBLUE CROSS BLUE SHIELD LA
LAF95311Medicare UPIN