| Organization Name: | SOUTHERN PEDIATRIC CLINIC |
| NPI Number: | 1104296417 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | STELLA GRACE IMMANUEL (OWNER) |
| Mailing Address: | 905 E 7th Ave Suite 9 Oakdale |
| State: | LA US |
| Postal Code: | 714632797 |
| Phone Number: | 3182158150 |
| Fax Number: | 3182158151 |
| NPI Enumeration Date: | 09/29/2015 |
| NPI Last Update Date: | 11/03/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QH0100X |
| License Number: | MD12866R |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | LA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Health Service |
| Taxonomy Definition: | |