Basic Information
Provider Information | |||||||||
NPI: | 1992103782 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AFFINITY HEALTH GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AFFINITY INDUSTRIAL MEDICINE CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 920 OLIVER RD | ||||||||
Address2: | SUITE D | ||||||||
City: | MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712015702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3188127559 | ||||||||
FaxNumber: | 3188127563 | ||||||||
Practice Location | |||||||||
Address1: | 130 DESIARD ST | ||||||||
Address2: | SUITE 355 | ||||||||
City: | MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712017319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3188077875 | ||||||||
FaxNumber: | 3188126603 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2014 | ||||||||
LastUpdateDate: | 12/11/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BREARD | ||||||||
AuthorizedOfficialFirstName: | MIKE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3183610900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0100X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine |
No ID Information.