MOSS STREET MEDICAL CLINIC INC NPI 1417085192

NPI Information

MOSS STREET MEDICAL CLINIC INC is a medical physician assistant in Lafayette, LA. MOSS STREET MEDICAL CLINIC INC NPI is 1417085192. The provider is registered as an organization entity type and is a single specialty group.

The provider's business location address is:

1417 MOSS ST
LAFAYETTE, LA
ZIP 70501-654
Phone: (337) 232-3371
Fax: (337) 232-3511

The provider's authorized official is Rickie Edward Johnson .
The authorized official title is Owner and has the following contact phone number (337) 232-3371.

The CLIA number assigned to this NPI record is 19D0961746 - independent with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 3/2/2007 and was last updated on 8/22/2020.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

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