Provider Demographics
NPI:1902173271
Name:ADULT MEDICINE AND DIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:ADULT MEDICINE AND DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HANNA
Authorized Official - Middle Name:KALINOWSKA
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-647-1947
Mailing Address - Street 1:2211 S BURNSIDE AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-4634
Mailing Address - Country:US
Mailing Address - Phone:225-647-1947
Mailing Address - Fax:225-644-3943
Practice Address - Street 1:2211 S BURNSIDE AVE STE 4
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4634
Practice Address - Country:US
Practice Address - Phone:225-647-1947
Practice Address - Fax:225-644-3943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022083261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1495859Medicaid
LAG58731Medicare UPIN
LA1495859Medicaid