Basic Information
Provider Information | |||||||||
NPI: | 1841257631 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TERREBONNE PARISH HOSPITAL SERVICE DISTRICT #1 | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TERREBONE GENERAL REHABILITATION UNIT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6037 | ||||||||
Address2: |   | ||||||||
City: | HOUMA | ||||||||
State: | LA | ||||||||
PostalCode: | 703616037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9858734235 | ||||||||
FaxNumber: | 9858514307 | ||||||||
Practice Location | |||||||||
Address1: | 8166 MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | HOUMA | ||||||||
State: | LA | ||||||||
PostalCode: | 70360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9858734141 | ||||||||
FaxNumber: | 9858514307 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2006 | ||||||||
LastUpdateDate: | 05/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YEATES | ||||||||
AuthorizedOfficialFirstName: | FRANCES | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9858734664 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA MBA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 159 | LA | Y |   | Hospital Units | Rehabilitation Unit |   |
ID Information
ID | Type | State | Issuer | Description | 1720275 | 05 | LA |   | MEDICAID | 5000076 | 01 | LA | UNITED HEALTHCARE | OTHER | 474543 | 01 | LA | AETNA | OTHER | 13064 | 01 | LA | BLUE CROSS PROFESSIONAL | OTHER | 61000 | 01 | LA | BLUE CROSS | OTHER |