Basic Information
| Provider Information | |||||||||
| NPI: | 1780870402 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAFAYETTE HEALTH VENTURES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRUCE JONES, MD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53092 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705053092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372898978 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 136 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372898978 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2007 | ||||||||
| LastUpdateDate: | 05/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | ROBILLARD | ||||||||
| AuthorizedOfficialFirstName: | BENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHYSICIAN PRACTICES | ||||||||
| AuthorizedOfficialTelephone: | 3372898972 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | MD.201685 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1029467 | 05 | LA | MEDICAID |