1326609462 NPI number — SPARKY JOEL TRAHAN PSS

Table of content: SPARKY JOEL TRAHAN PSS (NPI 1326609462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326609462 NPI number — SPARKY JOEL TRAHAN PSS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRAHAN
Provider First Name:
SPARKY
Provider Middle Name:
JOEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSS
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:
1326609462
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124A HOLLYWOOD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THIBODAUX
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70301-4322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-857-3615
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5599 HIGHWAY 311
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUMA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70360-2866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-857-3615
Provider Business Practice Location Address Fax Number:
985-876-8824
Provider Enumeration Date:
06/27/2019

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: 175T00000X , 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: 461634964 . This is a "PEER SUPPORT SPECIALLIST" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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