Provider Demographics
NPI:1902009350
Name:CHILDRENS CLINIC OF RACELAND LLC
Entity Type:Organization
Organization Name:CHILDRENS CLINIC OF RACELAND LLC
Other - Org Name:CHILDRENS CLINIC OF RACELAND
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUISA
Authorized Official - Middle Name:CUARIO
Authorized Official - Last Name:BACUTA-TAGORDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-537-8687
Mailing Address - Street 1:110 ACADIA PARK DR
Mailing Address - Street 2:
Mailing Address - City:RACELAND
Mailing Address - State:LA
Mailing Address - Zip Code:70394-2618
Mailing Address - Country:US
Mailing Address - Phone:985-537-8687
Mailing Address - Fax:985-537-8976
Practice Address - Street 1:110 ACADIA PARK DR
Practice Address - Street 2:
Practice Address - City:RACELAND
Practice Address - State:LA
Practice Address - Zip Code:70394-2618
Practice Address - Country:US
Practice Address - Phone:985-537-8687
Practice Address - Fax:985-537-8976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08233R208000000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1819336Medicaid
LA1394599Medicaid
5L496F948Medicare PIN