Provider Demographics
NPI:1821513508
Name:FOREVER KID PEDIATRIC PRACTICE
Entity Type:Organization
Organization Name:FOREVER KID PEDIATRIC PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:LUZ
Authorized Official - Last Name:LINARES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-461-2224
Mailing Address - Street 1:3321 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-3680
Mailing Address - Country:US
Mailing Address - Phone:504-461-2224
Mailing Address - Fax:504-461-2226
Practice Address - Street 1:3321 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065
Practice Address - Country:US
Practice Address - Phone:504-461-2224
Practice Address - Fax:504-461-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07446R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1373303Medicaid