1538342431 NPI number — MR. AMBROSE CARROLL THIBODEAUX JR. MT

Table of content: CALEB A ANDERSON PT (NPI 1497182760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538342431 NPI number — MR. AMBROSE CARROLL THIBODEAUX JR. MT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THIBODEAUX
Provider First Name:
AMBROSE
Provider Middle Name:
CARROLL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MT
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:
1538342431
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1015 CHOCTAW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OPELOUSAS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70570-6567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-934-6453
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 CHOCTAW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OPELOUSAS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70570-6567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-934-6453
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2007

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: 246QM0706X , with the licence number:  CLP.G02111-GEN , 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: 1499 . This is a "BRD CLIN LAB SCIEN PRACT" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 19554TCL-0 . This is a "BUR OF LIC & CERT." identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: CLP.G02111-GEN . This is a "ST BRD MEDICAL EXAMINES" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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