Provider Demographics
NPI:1962408781
Name:ARK-LA-TEX CHILDRENS CLINIC LLC
Entity type:Organization
Organization Name:ARK-LA-TEX CHILDRENS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LATIOLAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-742-6710
Mailing Address - Street 1:2400 HOSPITAL DR
Mailing Address - Street 2:STE 120
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2386
Mailing Address - Country:US
Mailing Address - Phone:318-742-6710
Mailing Address - Fax:318-747-5393
Practice Address - Street 1:2400 HOSPITAL DR
Practice Address - Street 2:STE 120
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2386
Practice Address - Country:US
Practice Address - Phone:318-742-6710
Practice Address - Fax:318-747-5393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0404240208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty