Basic Information
| Provider Information | |||||||||
| NPI: | 1740553569 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PELICAN CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 948 CAMBRIDGE DR STE 103B | ||||||||
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| City: | LA PLACE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700683647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856527717 | ||||||||
| FaxNumber: | 9856183611 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 FOURPARK PLACE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705072481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3378966440 | ||||||||
| FaxNumber: | 3378966441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2012 | ||||||||
| LastUpdateDate: | 01/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | HAYNES | ||||||||
| AuthorizedOfficialFirstName: | LETHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9544927150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 27302 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
No ID Information.