Basic Information
| Provider Information | |||||||||
| NPI: | 1508810649 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAFAYETTE HEALTH VENTURES. INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OB-GYN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53092 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705053092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3382898976 | ||||||||
| FaxNumber: | 3372898970 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 COOLIDGE BLVD | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372898440 | ||||||||
| FaxNumber: | 3372898442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 10/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | KIRK | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3382898951 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | VICE PRESIDENT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1712426 | 05 | LA | MEDICAID | CG2600 | 01 | LA | RAILROAD MEDICARE | OTHER |