1639122195 NPI number — MR. CALVIN DALE VIDRINE CRA RJ RN

Table of content: MR. CALVIN DALE VIDRINE CRA RJ RN (NPI 1639122195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639122195 NPI number — MR. CALVIN DALE VIDRINE CRA RJ RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIDRINE
Provider First Name:
CALVIN
Provider Middle Name:
DALE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRA RJ RN
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:
1639122195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1939
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:
70571-1939
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-942-1915
Provider Business Mailing Address Fax Number:
337-942-1990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
174 GRANT RD
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:
70570-0720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-594-9637
Provider Business Practice Location Address Fax Number:
337-948-4556
Provider Enumeration Date:
05/18/2006

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: 2085R0202X , with the licence number:  10041005 , 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: 1664669 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2000777340 . This is a "BCBS" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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