Basic Information
| Provider Information | |||||||||
| NPI: | 1952622664 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CCP MEDICAL MANAGEMENT LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHIPPS MANAGEMENT LLC MBR | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 FOURPARK RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705072481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3378966400 | ||||||||
| FaxNumber: | 3378966441 | ||||||||
| Practice Location | |||||||||
| Address1: | 213 FOURPARK RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705072481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3378966440 | ||||||||
| FaxNumber: | 3378966441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2010 | ||||||||
| LastUpdateDate: | 06/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | PHIPPS | ||||||||
| AuthorizedOfficialFirstName: | GROVER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3378966400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.