1023225356 NPI number — LAFAYETTE HEART CLINIC, LLC

Table of content: (NPI 1023225356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023225356 NPI number — LAFAYETTE HEART CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAFAYETTE HEART CLINIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023225356
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 AMBASSADOR CAFFERY PKWY
Provider Second Line Business Mailing Address:
PROVINCE, BUILDING 1
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-261-0928
Provider Business Mailing Address Fax Number:
337-233-7773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5000 AMBASSADOR CAFFERY PKWY
Provider Second Line Business Practice Location Address:
PROVINCE BUILDING 1
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-261-0928
Provider Business Practice Location Address Fax Number:
337-233-7773
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MALLAVARAPA
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
T
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
337-261-0928

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207UN0901X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1448460 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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