Provider Demographics
NPI:1992122642
Name:SOUTHERN PODIATRY CLINIC LLC
Entity type:Organization
Organization Name:SOUTHERN PODIATRY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:985-215-5618
Mailing Address - Street 1:537 KENTUCKY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-3913
Mailing Address - Country:US
Mailing Address - Phone:985-215-5618
Mailing Address - Fax:985-732-0100
Practice Address - Street 1:537 KENTUCKY AVE STE B
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3913
Practice Address - Country:US
Practice Address - Phone:985-215-5618
Practice Address - Fax:985-732-0100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADPM.200052261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric