Basic Information
Provider Information | |||||||||
NPI: | 1558791905 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOTAL FAMILY MEDICAL, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 14149 | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708984149 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2259300060 | ||||||||
FaxNumber: | 2259529075 | ||||||||
Practice Location | |||||||||
Address1: | 44354 HIGHWAY 445 STE D | ||||||||
Address2: |   | ||||||||
City: | ROBERT | ||||||||
State: | LA | ||||||||
PostalCode: | 704551999 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9855422466 | ||||||||
FaxNumber: | 9855422755 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2013 | ||||||||
LastUpdateDate: | 11/21/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GAUTREAU | ||||||||
AuthorizedOfficialFirstName: | PEGGY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9855422466 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.