Provider Demographics
NPI:1922146844
Name:LUBBOS MEDICAL CLINIC
Entity Type:Organization
Organization Name:LUBBOS MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MD
Authorized Official - Prefix:DR
Authorized Official - First Name:HANNA
Authorized Official - Middle Name:G
Authorized Official - Last Name:LUBBOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-239-7227
Mailing Address - Street 1:201 W ARKANSAS ST
Mailing Address - Street 2:P.O. BOX 780
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4752
Mailing Address - Country:US
Mailing Address - Phone:337-239-7227
Mailing Address - Fax:337-238-4299
Practice Address - Street 1:201 W ARKANSAS ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4752
Practice Address - Country:US
Practice Address - Phone:337-239-7227
Practice Address - Fax:337-238-4299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11793R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1948870Medicaid
LA1948870Medicaid
LA5CD07Medicare ID - Type Unspecified