Provider Demographics
NPI:1871732669
Name:DELTA MEDICAL PRACTICES, L.L.C.
Entity type:Organization
Organization Name:DELTA MEDICAL PRACTICES, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:GOODWIN
Authorized Official - Last Name:GLADNEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:318-281-0078
Mailing Address - Street 1:1523 TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-4043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-5033
Practice Address - Country:US
Practice Address - Phone:318-556-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty