Basic Information
| Provider Information | |||||||||
| NPI: | 1730854423 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 N ACADIA RD | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854354831 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1238 SAINT CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703602745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858729430 | ||||||||
| FaxNumber: | 9858729534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2021 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | BOUDREAUX | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | LEGENDRE | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9854934907 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | 08/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207XX0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 2086S0122X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 208VP0014X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.