Provider Demographics
NPI:1104084938
Name:ASCENSION MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:ASCENSION MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PRACTIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-647-6636
Mailing Address - Street 1:214 S BURNSIDE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-3463
Mailing Address - Country:US
Mailing Address - Phone:225-647-6636
Mailing Address - Fax:225-647-3849
Practice Address - Street 1:214 S BURNSIDE AVE STE A
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-3463
Practice Address - Country:US
Practice Address - Phone:225-647-6636
Practice Address - Fax:225-647-3849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD09828R208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty