Provider Demographics
NPI:1730808866
Name:SOUTHERN SPROUTS PEDIATRICS, LLC
Entity type:Organization
Organization Name:SOUTHERN SPROUTS PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:RACHAL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:318-729-4265
Mailing Address - Street 1:PO BOX 13211
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71315-3211
Mailing Address - Country:US
Mailing Address - Phone:318-777-6887
Mailing Address - Fax:
Practice Address - Street 1:217 BREVARD CT STE D
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3997
Practice Address - Country:US
Practice Address - Phone:318-777-6887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2130064Medicaid