Provider Demographics
NPI:1992793095
Name:ALLEN'S FAMILY PRACTICE CLINIC OF PONCHATOULA, L.L.P.
Entity type:Organization
Organization Name:ALLEN'S FAMILY PRACTICE CLINIC OF PONCHATOULA, L.L.P.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-386-6198
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-0129
Mailing Address - Country:US
Mailing Address - Phone:985-386-6198
Mailing Address - Fax:985-386-6223
Practice Address - Street 1:105 E OAK ST
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-2619
Practice Address - Country:US
Practice Address - Phone:985-386-6198
Practice Address - Fax:985-386-6223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1950009Medicaid
LA1950009Medicaid