Basic Information
| Provider Information | |||||||||
| NPI: | 1184791287 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AFFINITY HEALTH GROUP, LLC | ||||||||
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| OtherOrganizationName: | THE MEDICAL OFFICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 DESIARD ST | ||||||||
| Address2: | STE 355 | ||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712017319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188077875 | ||||||||
| FaxNumber: | 3188129997 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 SAINT JOHN ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712017322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183875681 | ||||||||
| FaxNumber: | 3183229957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 07/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | BREARD | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3183610900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP04747 | LA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | MD016846 | LA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.