Basic Information
| Provider Information | |||||||||
| NPI: | 1215355128 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION | ||||||||
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| OtherOrganizationName: | THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION - ENDOCRINOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5478 | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703025478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854933080 | ||||||||
| FaxNumber: | 9854934007 | ||||||||
| Practice Location | |||||||||
| Address1: | 726 N ACADIA RD | ||||||||
| Address2: | STE 3300 | ||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854933080 | ||||||||
| FaxNumber: | 9854934007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2014 | ||||||||
| LastUpdateDate: | 12/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | GAUBERT | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
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| AuthorizedOfficialTitleorPosition: | AGENT | ||||||||
| AuthorizedOfficialTelephone: | 9854934721 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.