Individual
ANTONIO DEMARCUS BROADWAY SR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
5810 MCCANN DR, BATON ROUGE, LA 70809-4149
(225) 221-7831
Mailing address
5810 MCCANN DR, BATON ROUGE, LA 70809-4149
(225) 221-7831
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
—
—
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0000
—
LA
Enumeration date
11/14/2017
Last updated
06/16/2018
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