1841497021 NPI number — BREEDLOVE MEDICAL, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841497021 NPI number — BREEDLOVE MEDICAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREEDLOVE MEDICAL, INC
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:
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:
1841497021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O 82207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70598
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-837-7776
Provider Business Mailing Address Fax Number:
337-837-7796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 BAYOU TORTUE RD
Provider Second Line Business Practice Location Address:
B 1
Provider Business Practice Location Address City Name:
BROUSSARD
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70518-7506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-837-7776
Provider Business Practice Location Address Fax Number:
337-837-7796
Provider Enumeration Date:
06/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EWING
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
L
Authorized Official Title or Position:
REGIONAL MGR
Authorized Official Telephone Number:
337-837-7776

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1477645001 , 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: 1165263 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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