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23699 Quail Lane Mandeville LA 70448-7334 | |
| (985) 334-4040 | |
| (985) 626-6549 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 23699 Quail Lane, Mandeville, Louisiana |
| Authorized Official Name and Position | Tony Shir (OFFICER) |
| Authorized Official Contact | 8474524565 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
7300 N Cicero Ave Suite 211 Lincolnwood IL 60712-1641 Ph: (224) 392-9889 | 23699 Quail Lane Mandeville LA 70448-7334 Ph: (985) 334-4040 |
| NPI Number | 1154855781 |
|---|---|
| Provider Enumeration Date | 04/20/2017 |
| Last Update Date | 10/17/2024 |
| Certification Date | 10/17/2024 |
| Medicare PECOS PAC ID | 9739457342 |
|---|---|
| Medicare Enrollment ID | O20170622000569 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1154855781 | NPI | - | NPPES |
| Provider Name | Shanta Marie Smith |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1427468503 PECOS PAC ID: 9436379922 Enrollment ID: I20141006000376 |
| Provider Name | Tyler Trenton Wansley |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1962035964 PECOS PAC ID: 4486079050 Enrollment ID: I20200730001845 |
| Provider Name | Sauntrice O'quin |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1194246686 PECOS PAC ID: 3870850563 Enrollment ID: I20201118000548 |
| Provider Name | Erik N Hanson |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1043714884 PECOS PAC ID: 3072860477 Enrollment ID: I20220928002104 |
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