Provider Demographics
NPI:1720353618
Name:DELTA MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:DELTA MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HIMES
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:504-392-3392
Mailing Address - Street 1:103 DOCTOR BOWEN ST
Mailing Address - Street 2:
Mailing Address - City:BELLE CHASSE
Mailing Address - State:LA
Mailing Address - Zip Code:70037-1505
Mailing Address - Country:US
Mailing Address - Phone:504-392-3392
Mailing Address - Fax:504-392-3303
Practice Address - Street 1:103 DOCTOR BOWEN ST
Practice Address - Street 2:
Practice Address - City:BELLE CHASSE
Practice Address - State:LA
Practice Address - Zip Code:70037-1505
Practice Address - Country:US
Practice Address - Phone:504-392-3392
Practice Address - Fax:504-392-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025901208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty