Provider Demographics
NPI:1174238752
Name:DIABETIC CARE CENTERS OF LOUISIANA INC
Entity type:Organization
Organization Name:DIABETIC CARE CENTERS OF LOUISIANA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-512-1176
Mailing Address - Street 1:7659 GILBERT ST.
Mailing Address - Street 2:SUITE D
Mailing Address - City:GILBERT
Mailing Address - State:LA
Mailing Address - Zip Code:71336-3427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7659 GILBERT ST.
Practice Address - Street 2:SUITE D
Practice Address - City:GILBERT
Practice Address - State:LA
Practice Address - Zip Code:71336
Practice Address - Country:US
Practice Address - Phone:318-657-1220
Practice Address - Fax:318-367-1376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-18
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty