Basic Information
| Provider Information | |||||||||
| NPI: | 1336607381 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED CARE PROFESSIONALS OF LOUSIANA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9178 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728119178 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 VENABLE LN STE 200 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712032028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554986767 | ||||||||
| FaxNumber: | 4799681673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2019 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | THOMASON | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5014066180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.