Basic Information
| Provider Information | |||||||||
| NPI: | 1952697088 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH LOUISIANA FOOT & ANKLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1302 LAKEWOOD DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MORGAN CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703801889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9853852616 | ||||||||
| FaxNumber: | 9853852618 | ||||||||
| Practice Location | |||||||||
| Address1: | 1302 LAKEWOOD DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MORGAN CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703801889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9853843338 | ||||||||
| FaxNumber: | 9853852618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2011 | ||||||||
| LastUpdateDate: | 03/04/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEONARDS | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9853852616 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | DPM.200026 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2165844 | 05 | LA | MEDICAID |