Provider Demographics
NPI:1902020019
Name:DOC 4 KIDS
Entity Type:Organization
Organization Name:DOC 4 KIDS
Other - Org Name:DOC 4 KIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:ENID
Authorized Official - Last Name:KOUBICEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-407-0084
Mailing Address - Street 1:1270 ATTAKAPAS DR STE 401 K
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-6549
Mailing Address - Country:US
Mailing Address - Phone:337-407-0084
Mailing Address - Fax:337-407-0094
Practice Address - Street 1:1270 ATTAKAPAS DR STE 401 K
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6549
Practice Address - Country:US
Practice Address - Phone:337-407-0084
Practice Address - Fax:337-407-0094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL#13448R261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAL#13448ROtherMED LICENSE
LA1565911Medicaid
LA1992855282OtherINDIVIDUAL NPI
LAF56899Medicare UPIN