Provider Demographics
NPI:1124457676
Name:PARADISE CHILDREN'S CLINIC OF LOUISIANA LLC
Entity type:Organization
Organization Name:PARADISE CHILDREN'S CLINIC OF LOUISIANA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-641-6113
Mailing Address - Street 1:4702 MONROE HWY
Mailing Address - Street 2:
Mailing Address - City:BALL
Mailing Address - State:LA
Mailing Address - Zip Code:71405-3944
Mailing Address - Country:US
Mailing Address - Phone:318-641-6113
Mailing Address - Fax:318-641-6115
Practice Address - Street 1:4702 MONROE HWY
Practice Address - Street 2:
Practice Address - City:BALL
Practice Address - State:LA
Practice Address - Zip Code:71405-3944
Practice Address - Country:US
Practice Address - Phone:318-641-6113
Practice Address - Fax:318-641-6115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2351192Medicaid
LA1453323Medicaid
LA1740405539OtherINDIVIDUAL NPI