Basic Information
| Provider Information | |||||||||
| NPI: | 1336245422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETTENCOURTT | ||||||||
| FirstName: | HEATH | ||||||||
| MiddleName: | LOUIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 LAPALCO BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GRETNA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043922580 | ||||||||
| FaxNumber: | 5043922527 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 LAPALCO BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GRETNA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043922580 | ||||||||
| FaxNumber: | 5043922527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 03/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 023017 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1483095 | 05 | LA | MEDICAID |