1134588908 NPI number — SHANRECA EUGENE DENNIS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134588908 NPI number — SHANRECA EUGENE DENNIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EUGENE DENNIS
Provider First Name:
SHANRECA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1134588908
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1605 CAPTAIN BOUTTE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEANERETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70544-6628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 N MAIN ST
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:
70570-6256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-942-6400
Provider Business Practice Location Address Fax Number:
337-948-7400
Provider Enumeration Date:
02/22/2016

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X , 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)





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