Provider Demographics
NPI:1417185307
Name:ASSURED MEDICAL GROUP, INC
Entity type:Organization
Organization Name:ASSURED MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:EWING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-334-7031
Mailing Address - Street 1:139B JAMES COMEAUX RD # 575
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3255
Mailing Address - Country:US
Mailing Address - Phone:337-334-7031
Mailing Address - Fax:225-208-1415
Practice Address - Street 1:200 AMERICAN LEGION DR
Practice Address - Street 2:
Practice Address - City:RAYNE
Practice Address - State:LA
Practice Address - Zip Code:70578-5826
Practice Address - Country:US
Practice Address - Phone:337-334-7031
Practice Address - Fax:225-208-1415
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASSURED MEDICAL HOLDINGS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA 15206253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LACC 03Medicaid