Basic Information
| Provider Information | |||||||||
| NPI: | 1750667481 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AFFINITY HEALTH GROUP, LLC | ||||||||
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| OtherOrganizationName: | AFFINITY WALK-IN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 DESIARD ST | ||||||||
| Address2: | SUITE 355 | ||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712017319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188077875 | ||||||||
| FaxNumber: | 3188129997 | ||||||||
| Practice Location | |||||||||
| Address1: | 2408 BROADMOOR BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712012994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188070525 | ||||||||
| FaxNumber: | 3188071077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2011 | ||||||||
| LastUpdateDate: | 05/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | JUSTICE | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3188077875 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 05/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 183500000X | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.