Provider Demographics
NPI:1538397542
Name:CENLA FAMILY MEDICINE ASSOCIATES, LLC
Entity type:Organization
Organization Name:CENLA FAMILY MEDICINE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DESIGNATED REGISTERED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCREPETIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-445-9823
Mailing Address - Street 1:P.O. BOX 5620
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5600
Mailing Address - Country:US
Mailing Address - Phone:318-445-9823
Mailing Address - Fax:318-445-1509
Practice Address - Street 1:1587 N BOLTON AVE
Practice Address - Street 2:SUITE 1100
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-4217
Practice Address - Country:US
Practice Address - Phone:318-445-9823
Practice Address - Fax:318-445-1509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018963207Q00000X
LA015029207Q00000X
LA024254207R00000X
LA019187207RC0000X
LA303310207RC0000X
LAPD20512213E00000X
LA200010213E00000X
LAAP01177363L00000X
LAAP06478363L00000X
LAAP0338363L00000X
LA018528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1810886Medicaid
LA1810886Medicaid