Provider Demographics
NPI:1770789760
Name:KD HEALTH & WELLNESS CENTER LLC
Entity type:Organization
Organization Name:KD HEALTH & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:DEDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWTON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:225-718-2190
Mailing Address - Street 1:118 JJJ LN
Mailing Address - Street 2:
Mailing Address - City:SIMMESPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71369-2180
Mailing Address - Country:US
Mailing Address - Phone:318-941-5287
Mailing Address - Fax:
Practice Address - Street 1:118 JJJ LN
Practice Address - Street 2:
Practice Address - City:SIMMESPORT
Practice Address - State:LA
Practice Address - Zip Code:71369-2180
Practice Address - Country:US
Practice Address - Phone:318-941-5287
Practice Address - Fax:318-941-5284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA19-3892OtherMEDICARE RURAL HEALTH CCN
=========OtherEIN