Basic Information
| Provider Information | |||||||||
| NPI: | 1689722431 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BATON ROUGE PRIMARY CARE COLLABORATIVE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BATON ROUGE PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2013 CENTRAL ROAD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708073918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257741120 | ||||||||
| FaxNumber: | 2257741158 | ||||||||
| Practice Location | |||||||||
| Address1: | 2013 CENTRAL ROAD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708073918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257441120 | ||||||||
| FaxNumber: | 2257741158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLAND | ||||||||
| AuthorizedOfficialFirstName: | STACIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2253541914 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.