1699208868 NPI number — DR. KALLIE R LEBOURGEOIS AU.D.

Table of content: DR. KALLIE R LEBOURGEOIS AU.D. (NPI 1699208868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699208868 NPI number — DR. KALLIE R LEBOURGEOIS AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEBOURGEOIS
Provider First Name:
KALLIE
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
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:
1699208868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2024
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:
8080 BLUEBONNET BLVD
Provider Second Line Business Practice Location Address:
SUITE 2121
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70810-7827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-408-6734
Provider Business Practice Location Address Fax Number:
225-766-3851
Provider Enumeration Date:
04/05/2017

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:  7586 , 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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