Basic Information
| Provider Information | |||||||||
| NPI: | 1699218131 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH LOUISIANA MEDICAL ASSOCIATES | ||||||||
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| OtherOrganizationName: | SLMA COMPREHENSIVE HEALTHCARE CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1990 INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703637055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858689300 | ||||||||
| FaxNumber: | 9858510053 | ||||||||
| Practice Location | |||||||||
| Address1: | 144 VALHI LAGOON XING | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703603208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9852621639 | ||||||||
| FaxNumber: | 9852628197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2016 | ||||||||
| LastUpdateDate: | 02/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9858689300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | LA | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1441830 | 05 | LA | MEDICAID | 1792314 | 05 | LA | MEDICAID |