| Moss Street Kid Med Llc | |
|
1417a Moss Street Lafayette LA 70501 | |
| (337) 291-2411 | |
| (337) 291-2412 |
| Full Name | Moss Street Kid Med Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 1417a Moss Street, Lafayette, Louisiana |
| Authorized Official Name and Position | Desiree P Richard (ONWER) |
| Authorized Official Contact | 3372912411 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Moss Street Kid Med Llc 1417a Moss St Lafayette LA 70501-3654 Ph: (337) 291-2411 | Moss Street Kid Med Llc 1417a Moss Street Lafayette LA 70501 Ph: (337) 291-2411 |
| NPI Number | 1336268184 |
|---|---|
| Provider Enumeration Date | 03/29/2007 |
| Last Update Date | 03/25/2009 |
| Medicare PECOS PAC ID | 1355694498 |
|---|---|
| Medicare Enrollment ID | O20181019000595 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1336268184 | NPI | - | NPPES |
| 1949221 | Medicaid | LA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (Louisiana) | Primary |
| Provider Name | Shavondali H Cawthorne |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1881204808 PECOS PAC ID: 8224446703 Enrollment ID: I20210422000206 |
| Provider Name | Michael R Melancon |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1992737621 PECOS PAC ID: 1850790619 Enrollment ID: I20210527000549 |
| Provider Name | Windi Calvert Sullivan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1780303305 PECOS PAC ID: 3577933472 Enrollment ID: I20230111001234 |
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