Provider Demographics
NPI:1952897688
Name:MMG ARCHER INSTITUTE, LLC
Entity Type:Organization
Organization Name:MMG ARCHER INSTITUTE, LLC
Other - Org Name:MMG ARCHER INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON-HATCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-494-2094
Mailing Address - Street 1:PO BOX 123977 DEPT 3977
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-0001
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:2829 4TH AVE STE 150
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7897
Practice Address - Country:US
Practice Address - Phone:337-480-7800
Practice Address - Fax:337-474-4552
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-05
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2509551Medicaid