1366816761 NPI number — TRAILLE MEDICAL SPECIALTIES, LLC

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 1366816761 NPI number — TRAILLE MEDICAL SPECIALTIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRAILLE MEDICAL SPECIALTIES, 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:
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:
1366816761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
623 S BURGESS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70815-5202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-678-4471
Provider Business Mailing Address Fax Number:
225-364-2062

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
606 COLONIAL DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70806-6535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-330-4956
Provider Business Practice Location Address Fax Number:
225-364-2062
Provider Enumeration Date:
11/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ROEDEMA
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
225-678-4471

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  53785 , 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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