Provider Demographics
NPI:1831491141
Name:KISATCHIE MEDICAL LLC
Entity Type:Organization
Organization Name:KISATCHIE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:CHRISTINA
Authorized Official - Last Name:GODEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-473-1921
Mailing Address - Street 1:3425 NORTH BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3608
Mailing Address - Country:US
Mailing Address - Phone:318-473-1921
Mailing Address - Fax:318-473-1922
Practice Address - Street 1:3425 NORTH BLVD STE A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3608
Practice Address - Country:US
Practice Address - Phone:318-473-1921
Practice Address - Fax:318-473-1922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty