Organization
MOSS STREET MEDICAL CLINIC INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RICKIE EDWARD JOHNSON PA (OWNER)
(337) 232-3371
Entity
Organization
Contact information
Practice address
1417 MOSS ST, LAFAYETTE, LA 70501-3654
(337) 232-3371
(337) 232-3511
Mailing address
1417 MOSS ST, LAFAYETTE, LA 70501-3654
(337) 232-3371
(337) 232-3511
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
A10226
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1448397
—
LA
Enumeration date
03/02/2007
Last updated
08/22/2020
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