Basic Information
Provider Information | |||||||||
NPI: | 1477159333 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AFFINITY HEALTH GROUP LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 130 DESIARD ST STE 355 | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712017363 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3189983426 | ||||||||
FaxNumber: | 1881266033 | ||||||||
Practice Location | |||||||||
Address1: | 2516 BROADMOOR BLVD STE 3A | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712012988 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3183879420 | ||||||||
FaxNumber: | 3183238216 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/07/2020 | ||||||||
LastUpdateDate: | 12/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JUSTICE | ||||||||
AuthorizedOfficialFirstName: | JANET | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 3188077875 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
No ID Information.