Provider Demographics
NPI:1265499628
Name:PEDIATRIC GROUP OF ACADIANA, LLC
Entity Type:Organization
Organization Name:PEDIATRIC GROUP OF ACADIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COLLECTOR/BILLER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-330-0031
Mailing Address - Street 1:401 YOUNGSVILLE HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5173
Mailing Address - Country:US
Mailing Address - Phone:337-330-0031
Mailing Address - Fax:337-330-0059
Practice Address - Street 1:401 YOUNGSVILLE HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5173
Practice Address - Country:US
Practice Address - Phone:337-330-0031
Practice Address - Fax:337-330-0059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1440604Medicaid
LA1440604Medicaid
LA1440604Medicaid