Basic Information
| Provider Information | |||||||||
| NPI: | 1669598322 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACADIANA CENTER FOR ORTHOPEDIC & OCCUPATIONAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 WEST PINHOOK ROAD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372690136 | ||||||||
| FaxNumber: | 3372338525 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 WEST PINHOOK ROAD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372690136 | ||||||||
| FaxNumber: | 3372338525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 02/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | LEVASSEUR | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | DEPRIEST | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3372690136 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 012306 | LA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1457591 | 05 | LA | MEDICAID |