Provider Demographics
NPI:1245245000
Name:UNIVERSITY OF LOUISIANA AT LAFAYETTE
Entity Type:Organization
Organization Name:UNIVERSITY OF LOUISIANA AT LAFAYETTE
Other - Org Name:UL LAFAYETTE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR, ULLAFAYETTE SHS
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:MARELLE
Authorized Official - Last Name:YONGUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-482-6826
Mailing Address - Street 1:PO BOX 43692
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70504-0001
Mailing Address - Country:US
Mailing Address - Phone:337-482-6826
Mailing Address - Fax:
Practice Address - Street 1:120 BOUCHER DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70504-0001
Practice Address - Country:US
Practice Address - Phone:337-482-6826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health