Provider Demographics
NPI:1306269360
Name:WEST MONROE FAMILY PRACTICE CLINIC
Entity type:Organization
Organization Name:WEST MONROE FAMILY PRACTICE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-398-2680
Mailing Address - Street 1:PO BOX 2673
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71294-2673
Mailing Address - Country:US
Mailing Address - Phone:318-398-2680
Mailing Address - Fax:318-322-2885
Practice Address - Street 1:2933 CYPRESS ST STE 1
Practice Address - Street 2:HALL A
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5337
Practice Address - Country:US
Practice Address - Phone:318-398-2680
Practice Address - Fax:318-322-2885
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ONE SOURCE MEDICAL MANAGEMENT, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-28
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2356232Medicaid