1639118078 NPI number — ST MICHAEL PFU LLC

Table of content: (NPI 1639118078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639118078 NPI number — ST MICHAEL PFU LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST MICHAEL PFU LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE CARE CENTER OF DEQUINCY
Provider Other Organization Name Type Code:
3
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:
1639118078
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1219
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEQUINCY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70633-1219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-786-2466
Provider Business Mailing Address Fax Number:
337-786-6266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 N DIVISION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEQUINCY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70633-3129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-786-2466
Provider Business Practice Location Address Fax Number:
337-786-6266
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROUSSARD
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
CPA
Authorized Official Telephone Number:
337-639-2934

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  857 , 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: 1510661 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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