Basic Information
Provider Information | |||||||||
NPI: | 1053722066 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AFFINITY HEALTH GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AFFINITY HEALTH MANAGEMENT CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 130 DESIARD ST | ||||||||
Address2: | SUITE 355 | ||||||||
City: | MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712017319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3188077875 | ||||||||
FaxNumber: | 3188126603 | ||||||||
Practice Location | |||||||||
Address1: | 1325 LOUISVILLE AVE | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712016021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3188071500 | ||||||||
FaxNumber: | 3188071504 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2014 | ||||||||
LastUpdateDate: | 05/13/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BREARD | ||||||||
AuthorizedOfficialFirstName: | MIKE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP | ||||||||
AuthorizedOfficialTelephone: | 3183610900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 133V00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 225100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 235Z00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.