Provider Demographics
NPI:1609681345
Name:MED ONE HEALTH CLINIC, LLC
Entity type:Organization
Organization Name:MED ONE HEALTH CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LATRISALA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:832-870-8375
Mailing Address - Street 1:349 DOGWOOD SOUTH LN
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-8511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:349 DOGWOOD SOUTH LN
Practice Address - Street 2:
Practice Address - City:HAUGHTON
Practice Address - State:LA
Practice Address - Zip Code:71037-8511
Practice Address - Country:US
Practice Address - Phone:832-870-8375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-10
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty