Provider Demographics
NPI:1831120740
Name:ANGIE MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:ANGIE MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DONICE
Authorized Official - Middle Name:JEFFERSON
Authorized Official - Last Name:RAYFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-986-0016
Mailing Address - Street 1:29764 HIGHWAY 21
Mailing Address - Street 2:
Mailing Address - City:ANGIE
Mailing Address - State:LA
Mailing Address - Zip Code:70426-3069
Mailing Address - Country:US
Mailing Address - Phone:985-986-0016
Mailing Address - Fax:985-986-1260
Practice Address - Street 1:29764 HIGHWAY 21
Practice Address - Street 2:
Practice Address - City:ANGIE
Practice Address - State:LA
Practice Address - Zip Code:70426-3069
Practice Address - Country:US
Practice Address - Phone:985-986-0016
Practice Address - Fax:985-986-1260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1117820Medicaid
ME1104264Medicaid
LA55669Medicare ID - Type UnspecifiedFAMILY PRACTICE
LA1104264Medicare ID - Type UnspecifiedFAMILY PRACTICE
ME1104264Medicaid
LA1117820Medicaid