Basic Information
| Provider Information | |||||||||
| NPI: | 1750586541 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CHILDREN'S CLINIC OF THIBODAUX ,L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 807 RIDGEFIELD RD | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703012725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854479045 | ||||||||
| FaxNumber: | 9854473349 | ||||||||
| Practice Location | |||||||||
| Address1: | 807 RIDGEFIELD RD | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703012725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854479045 | ||||||||
| FaxNumber: | 9854473349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PITRE | ||||||||
| AuthorizedOfficialFirstName: | SHEILA | ||||||||
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| AuthorizedOfficialTitleorPosition: | M.D. | ||||||||
| AuthorizedOfficialTelephone: | 9854479045 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 09890R | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.