Provider Demographics
NPI:1164088134
Name:LISA BREAUX BLACK, MD
Entity Type:Organization
Organization Name:LISA BREAUX BLACK, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MALBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-665-9173
Mailing Address - Street 1:895 VERRET ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4635
Mailing Address - Country:US
Mailing Address - Phone:985-200-3225
Mailing Address - Fax:985-746-1204
Practice Address - Street 1:895 VERRET ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4635
Practice Address - Country:US
Practice Address - Phone:985-200-3225
Practice Address - Fax:985-746-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care