1376864140 NPI number — LOREN CHRISTIAN THIBODEAUX AU.D.

Table of content: LOREN CHRISTIAN THIBODEAUX AU.D. (NPI 1376864140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376864140 NPI number — LOREN CHRISTIAN THIBODEAUX AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THIBODEAUX
Provider First Name:
LOREN
Provider Middle Name:
CHRISTIAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
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:
1376864140
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
604 N ACADIA RD STE 101
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:
70301-4897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-446-5079
Provider Business Mailing Address Fax Number:
985-447-2497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4630 AMBASSADOR CAFFERY PKWY
Provider Second Line Business Practice Location Address:
BUILDING A SUITE 402
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70508-6949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-988-6798
Provider Business Practice Location Address Fax Number:
337-989-2289
Provider Enumeration Date:
06/16/2010

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: 237600000X , with the licence number:  6333 , 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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