Provider Demographics
NPI:1053450668
Name:MOBILE DIAGNOSTICS OF LAFAYETTE LLC
Entity Type:Organization
Organization Name:MOBILE DIAGNOSTICS OF LAFAYETTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:337-235-0888
Mailing Address - Street 1:PO BOX 52970
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-2970
Mailing Address - Country:US
Mailing Address - Phone:337-235-0888
Mailing Address - Fax:337-237-3700
Practice Address - Street 1:155 HOSPITAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2852
Practice Address - Country:US
Practice Address - Phone:337-235-0888
Practice Address - Fax:337-237-3700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAF9591OtherBLUECROSS BLUESHIELD
LAF9591OtherBLUECROSS BLUESHIELD