Provider Demographics
NPI:1447705074
Name:SOUTH LOUISIANA PRIMARY CARE LLC
Entity type:Organization
Organization Name:SOUTH LOUISIANA PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:LOGUE
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:225-774-0733
Mailing Address - Street 1:12902 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-4911
Mailing Address - Country:US
Mailing Address - Phone:225-774-0733
Mailing Address - Fax:225-774-7777
Practice Address - Street 1:12902 PLANK RD
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-4911
Practice Address - Country:US
Practice Address - Phone:225-218-4816
Practice Address - Fax:225-302-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
LAAP06078261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2110691Medicaid