Basic Information
| Provider Information | |||||||||
| NPI: | 1487974044 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAFAYETTE HEALTH VENTURES INC | ||||||||
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| OtherOrganizationName: | BRENT MAHONEY MD, PHD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53092 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705053092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377061533 | ||||||||
| FaxNumber: | 3377697164 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 HOSPITAL DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372898067 | ||||||||
| FaxNumber: | 3372898066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2010 | ||||||||
| LastUpdateDate: | 06/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | HUVAL | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3372898969 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAFAYETTE HEALTH VENTURES INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 202954 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.