Basic Information
| Provider Information | |||||||||
| NPI: | 1043318082 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHC -OPELOUSAS LP | ||||||||
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| OtherOrganizationName: | DOCTORS HOSPITAL OF OPELOUSAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 POWELL CT | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153728500 | ||||||||
| FaxNumber: | 6153728572 | ||||||||
| Practice Location | |||||||||
| Address1: | 3983 I-49 SOUTH SERVICE ROAD | ||||||||
| Address2: | |||||||||
| City: | OPELOUSAS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379482107 | ||||||||
| FaxNumber: | 3379482173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 09/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | GRACEY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | 417 | LA | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 1766984 | 05 | LA | MEDICAID |