Provider Demographics
NPI:1700092442
Name:PROVIDENCE MEDICAL CLINIC
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CUONG
Authorized Official - Middle Name:MINH
Authorized Official - Last Name:PHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-766-8152
Mailing Address - Street 1:1229 TANGLEBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-5195
Mailing Address - Country:US
Mailing Address - Phone:225-766-4213
Mailing Address - Fax:
Practice Address - Street 1:9270 SIEGEN LN
Practice Address - Street 2:SUITE 202
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1998
Practice Address - Country:US
Practice Address - Phone:225-766-8152
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care