Provider Demographics
NPI:1720008675
Name:MINOR MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:MINOR MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:ARPN
Authorized Official - Phone:337-217-0922
Mailing Address - Street 1:109 EXECUTIVE DR.
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70611-5328
Mailing Address - Country:US
Mailing Address - Phone:337-217-0922
Mailing Address - Fax:337-217-0925
Practice Address - Street 1:109 EXECUTIVE DR.
Practice Address - Street 2:SUITE C
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-5328
Practice Address - Country:US
Practice Address - Phone:337-217-0922
Practice Address - Fax:337-217-0925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service