Provider Demographics
NPI:1245542661
Name:INLAND CARDIOVASCULAR CLINIC
Entity type:Organization
Organization Name:INLAND CARDIOVASCULAR CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-330-9330
Mailing Address - Street 1:PO BOX 1711
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71210-1711
Mailing Address - Country:US
Mailing Address - Phone:318-330-9330
Mailing Address - Fax:318-330-9517
Practice Address - Street 1:614 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6236
Practice Address - Country:US
Practice Address - Phone:318-330-9330
Practice Address - Fax:318-330-9517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11738R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
32980820A1OtherBLUE CROSS/BLUE SHIELD
LA1681903Medicaid
AR136103002Medicaid
AR136103002Medicaid
LA5W835Medicare PIN