Basic Information
| Provider Information | |||||||||
| NPI: | 1801207436 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMPERIAL HEALTH LLP | ||||||||
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| OtherOrganizationName: | VEIN CENTER OF SOUTHWEST LOUISIANA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 DR MICHAEL DEBAKEY DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706015724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374338400 | ||||||||
| FaxNumber: | 3373126708 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 KALISTE SALOOM RD | ||||||||
| Address2: | BLDG 2, STE 201 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705086112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375348346 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2014 | ||||||||
| LastUpdateDate: | 05/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | BROACH | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3379905510 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.