Provider Demographics
NPI:1306343561
Name:MOAB LLC
Entity type:Organization
Organization Name:MOAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:VITA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-802-6936
Mailing Address - Street 1:921 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-3424
Mailing Address - Country:US
Mailing Address - Phone:337-527-6385
Mailing Address - Fax:337-527-3527
Practice Address - Street 1:921 1ST AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-3424
Practice Address - Country:US
Practice Address - Phone:337-527-6385
Practice Address - Fax:337-527-3527
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEVIN T. SCHLAMP, MD, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10408R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty