Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 2641 | LA |
Y | 213EG0000X | General Practice | 2641 | LA |
NPI | 1003949678 |
---|---|
Provider Name | Dr. Chester Lee Ellender |
First Address | Sulphur, LA 70663-3425 |
Second Address | Sulphur, LA 70663-3425 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1826413 | (05) | LA |