1376502351 NPI number — CLARK LEBLANC PT

Table of content: CLARK LEBLANC PT (NPI 1376502351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376502351 NPI number — CLARK LEBLANC PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEBLANC
Provider First Name:
CLARK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376502351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 875
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREAUX BRIDGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70517-0875
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-332-6120
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 BERARD ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BREAUX BRIDGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70517-4865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-332-6120
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1006 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 650016821 E0303 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1183605 . This is a "CIGNA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: B4436 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 70517 A004 . This is a "CHAMPUS" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".