Provider Demographics
NPI:1861487290
Name:THE FOOT CLINIC OF WEST LOUISIANA
Entity Type:Organization
Organization Name:THE FOOT CLINIC OF WEST LOUISIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:337-239-1061
Mailing Address - Street 1:1108 PORT ARTHUR TER
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4600
Mailing Address - Country:US
Mailing Address - Phone:337-239-1061
Mailing Address - Fax:337-239-1062
Practice Address - Street 1:1108 PORT ARTHUR TER
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4600
Practice Address - Country:US
Practice Address - Phone:337-239-1061
Practice Address - Fax:337-239-1062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1442348Medicaid
LA1442348Medicaid