Provider Demographics
NPI:1053594507
Name:DANIELS FAMILY MEDICAL CENTER LLC
Entity type:Organization
Organization Name:DANIELS FAMILY MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:CLYDE
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-934-0082
Mailing Address - Street 1:PO BOX 7276
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71137-7276
Mailing Address - Country:US
Mailing Address - Phone:318-934-0082
Mailing Address - Fax:
Practice Address - Street 1:3736 N MARKET ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-3104
Practice Address - Country:US
Practice Address - Phone:318-934-0082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06282R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1352896Medicaid
LA1352896Medicaid