Basic Information
Provider Information
NPI: 1386066769
EntityType: 2
ReplacementNPI:  
OrganizationName: ACADIANA CENTER LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: ACADIANA CENTER LLC
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2501 W PINHOOK RD
Address2:  
City: LAFAYETTE
State: LA
PostalCode: 705083346
CountryCode: US
TelephoneNumber: 3372690136
FaxNumber:  
Practice Location
Address1: 2501 W PINHOOK RD
Address2:  
City: LAFAYETTE
State: LA
PostalCode: 705083346
CountryCode: US
TelephoneNumber: 3372690136
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/20/2014
LastUpdateDate: 11/06/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: GIDMAN
AuthorizedOfficialFirstName: GORDON
AuthorizedOfficialMiddleName: G
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 3372690136
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QU0200X  Y Ambulatory Health Care FacilitiesClinic/CenterUrgent Care

No ID Information.


Home