Provider Demographics
NPI:1427236660
Name:GOODWOOD PRIMARY CARE CLINIC, LLC
Entity type:Organization
Organization Name:GOODWOOD PRIMARY CARE CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:225-952-9460
Mailing Address - Street 1:8333 GOODWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7744
Mailing Address - Country:US
Mailing Address - Phone:225-952-9460
Mailing Address - Fax:225-952-9459
Practice Address - Street 1:8333 GOODWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7744
Practice Address - Country:US
Practice Address - Phone:225-952-9460
Practice Address - Fax:225-952-9459
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NONE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-08
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DC45Medicare PIN