Basic Information
| Provider Information | |||||||||
| NPI: | 1366946030 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S INTERNATIONAL, LLC | ||||||||
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| OtherOrganizationName: | CHILDREN'S INTERNATIONAL MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 59101 AMBER ST | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704613708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856461580 | ||||||||
| FaxNumber: | 8888634274 | ||||||||
| Practice Location | |||||||||
| Address1: | 1828 W THOMAS ST | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704012958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854192250 | ||||||||
| FaxNumber: | 9854192252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2018 | ||||||||
| LastUpdateDate: | 03/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | ZACH | ||||||||
| AuthorizedOfficialMiddleName: | HAYS | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 9856461580 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 1020303 | 05 | LA | MEDICAID |