Provider Demographics
NPI:1093076275
Name:OUR LADY OF LOURDES REGIONAL
Entity Type:Organization
Organization Name:OUR LADY OF LOURDES REGIONAL
Other - Org Name:JOHN S THIBODEAUX MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-470-2593
Mailing Address - Street 1:4801 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6917
Mailing Address - Country:US
Mailing Address - Phone:337-470-2593
Mailing Address - Fax:
Practice Address - Street 1:402 E EDWARD ST
Practice Address - Street 2:
Practice Address - City:ERATH
Practice Address - State:LA
Practice Address - Zip Code:70533-4114
Practice Address - Country:US
Practice Address - Phone:337-937-5803
Practice Address - Fax:337-937-5806
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF LOURDES REGIONAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-04
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty