Provider Demographics
NPI:1083921944
Name:THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Entity Type:Organization
Organization Name:THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Other - Org Name:THIBODAUX REGIONAL RHEUMATOLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:LEGENDRE
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-493-4907
Mailing Address - Street 1:PO BOX 5478
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:985-449-4656
Mailing Address - Fax:985-449-2532
Practice Address - Street 1:726 N ACADIA RD
Practice Address - Street 2:STE 3400
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4847
Practice Address - Country:US
Practice Address - Phone:985-449-4656
Practice Address - Fax:985-449-2532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2420852Medicaid
LA5DQ64Medicare PIN