1659762839 NPI number — DERRICK THIBODEAUX N.P.

Table of content: DERRICK THIBODEAUX N.P. (NPI 1659762839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659762839 NPI number — DERRICK THIBODEAUX N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THIBODEAUX
Provider First Name:
DERRICK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
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:
1659762839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1303 HORRIDGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VINTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70668-4531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-324-8060
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1303 HORRIDGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VINTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70668-4531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-324-8060
Provider Business Practice Location Address Fax Number:
337-324-8061
Provider Enumeration Date:
02/10/2015

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: 363LF0000X , with the licence number:  AP08118 , 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: AP08118 . This is a "LOUISIANA STATE BOARD OF NURSING" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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