1396175857 NPI number — THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION

Table of content: (NPI 1396175857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396175857 NPI number — THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
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:
6
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:
1396175857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5478
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:
70302-5478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-493-4004
Provider Business Mailing Address Fax Number:
985-493-4007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
726 N ACADIA RD
Provider Second Line Business Practice Location Address:
STE 2400
Provider Business Practice Location Address City Name:
THIBODAUX
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70301-4847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-493-4090
Provider Business Practice Location Address Fax Number:
985-493-4081
Provider Enumeration Date:
11/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BOUDREAUX
Authorized Official First Name:
KIM
Authorized Official Middle Name:
LEGENDRE
Authorized Official Title or Position:
CONTRACT MANAGER
Authorized Official Telephone Number:
985-493-4907

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2395131 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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