Basic Information
Provider Information | |||||||||
NPI: | 1447854294 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5478 | ||||||||
Address2: |   | ||||||||
City: | THIBODAUX | ||||||||
State: | LA | ||||||||
PostalCode: | 703025478 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9854354831 | ||||||||
FaxNumber: | 9854492513 | ||||||||
Practice Location | |||||||||
Address1: | 807 RIDGEFIELD RD | ||||||||
Address2: |   | ||||||||
City: | THIBODAUX | ||||||||
State: | LA | ||||||||
PostalCode: | 703012725 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9854479045 | ||||||||
FaxNumber: | 9854473349 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/23/2020 | ||||||||
LastUpdateDate: | 11/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOUDREAUX | ||||||||
AuthorizedOfficialFirstName: | KIM | ||||||||
AuthorizedOfficialMiddleName: | LEGENDRE | ||||||||
AuthorizedOfficialTitleorPosition: | CONTRACT MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9854934907 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 2080A0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208M00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.