Provider Demographics
NPI:1922876960
Name:INDEPENDENCE FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:INDEPENDENCE FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:TATE
Authorized Official - Suffix:JR
Authorized Official - Credentials:FNP
Authorized Official - Phone:985-878-4183
Mailing Address - Street 1:312 E RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:70443-2710
Mailing Address - Country:US
Mailing Address - Phone:985-878-4183
Mailing Address - Fax:
Practice Address - Street 1:312 E RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:LA
Practice Address - Zip Code:70443-2710
Practice Address - Country:US
Practice Address - Phone:985-878-4183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty