Basic Information
| Provider Information | |||||||||
| NPI: | 1114339181 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION - NEUROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5478 | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703025478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854933090 | ||||||||
| FaxNumber: | 9854933091 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 N ACADIA RD | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854933090 | ||||||||
| FaxNumber: | 9854933091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2014 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | BOUDREAUX | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | LEGENDRE | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9854934907 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 2376365 | 05 | LA | MEDICAID |