Basic Information
| Provider Information | |||||||||
| NPI: | 1952897688 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MMG ARCHER INSTITUTE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MMG ARCHER INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 123977 DEPT 3977 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753120001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942921 | ||||||||
| FaxNumber: | 3374946523 | ||||||||
| Practice Location | |||||||||
| Address1: | 2829 4TH AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706017897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374807800 | ||||||||
| FaxNumber: | 3374744552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2018 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON-HATCHER | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3374942094 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMORIAL MEDICAL GROUP | ||||||||
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| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 2509551 | 05 | LA | MEDICAID |