Provider Demographics
NPI:1215294830
Name:SOUTHCARE MEDICAL LLC
Entity type:Organization
Organization Name:SOUTHCARE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRISTYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUGENG
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:337-422-6240
Mailing Address - Street 1:1305 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70510-2825
Mailing Address - Country:US
Mailing Address - Phone:337-422-6240
Mailing Address - Fax:337-422-6241
Practice Address - Street 1:1305 N STATE ST
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70510-2825
Practice Address - Country:US
Practice Address - Phone:337-422-6240
Practice Address - Fax:337-422-6241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD200292208000000X, 208000000X, 207P00000X
LA2203782387261QR1300X, 261QR1300X
LAAP07807363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2203782387OtherDHH RHC
LA33165OtherLA BOARD OF PHARMACY
LA19D2035943OtherCLIA WAIVER
LA2406922Medicaid
LA2406922Medicaid
LA9627021OtherDEA