Basic Information
| Provider Information | |||||||||
| NPI: | 1316604762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 N ACADIA RD | ||||||||
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| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854934907 | ||||||||
| FaxNumber: | 9854492585 | ||||||||
| Practice Location | |||||||||
| Address1: | 726 N. ACADIA ROAD | ||||||||
| Address2: | EDUCATION SUITE | ||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854934004 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2021 | ||||||||
| LastUpdateDate: | 11/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | BOUDREAUX | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | LEGENDRE | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9854934907 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.