Provider Demographics
NPI:1740553569
Name:PELICAN CLINIC LLC
Entity type:Organization
Organization Name:PELICAN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LETHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-492-7150
Mailing Address - Street 1:948 CAMBRIDGE DR STE 103B
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-3647
Mailing Address - Country:US
Mailing Address - Phone:985-652-7717
Mailing Address - Fax:985-618-3611
Practice Address - Street 1:948 CAMBRIDGE DR STE 103B
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-3647
Practice Address - Country:US
Practice Address - Phone:985-652-7717
Practice Address - Fax:337-896-6441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA27302207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty