Basic Information
| Provider Information | |||||||||
| NPI: | 1851532964 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THIBODAUX REGIONAL HEART & VASCULAR CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5478 | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703025478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854475500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 604 N ACADIA RD | ||||||||
| Address2: | SUITE 409 | ||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854475500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2009 | ||||||||
| LastUpdateDate: | 08/03/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOUDREAUX | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | LEGENDRE | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9854934907 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 208G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1800856 | 05 | LA | MEDICAID |