Organization
SOUTHERN PEDIATRIC CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
STELLA GRACE IMMANUEL MD (OWNER)
(318) 221-0277
Entity
Organization
Contact information
Practice address
202 N THOMAS DR, SUITE 1, SHREVEPORT, LA 71107-6539
(318) 221-0277
(318) 221-3277
Mailing address
202 N THOMAS DR, SUITE 1, SHREVEPORT, LA 71107-6539
(318) 221-0277
(318) 221-3277
Taxonomy
Speciality
Code
Description
License number
State
261QH0100X
Health Service Clinic/Center
Primary
MD12866R
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1449237
—
LA
Enumeration date
10/08/2015
Last updated
11/03/2015
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