Basic Information
| Provider Information | |||||||||
| NPI: | 1467687186 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAFAYETTE HEALTH VENTURES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53092 | ||||||||
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| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705053092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372898933 | ||||||||
| FaxNumber: | 3372898982 | ||||||||
| Practice Location | |||||||||
| Address1: | 461 HEYMANN BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372335300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2009 | ||||||||
| LastUpdateDate: | 10/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | PATIN | ||||||||
| AuthorizedOfficialFirstName: | AL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ADMINSTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3372898933 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1195367 | 05 | LA | MEDICAID | CG2600 | 01 | LA | RAILROAD MEDICARE | OTHER |