Provider Demographics
NPI:1285005967
Name:PREVENTION PLUS OF THIBODAUX LLC
Entity Type:Organization
Organization Name:PREVENTION PLUS OF THIBODAUX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:PERQUE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:985-492-9100
Mailing Address - Street 1:PO BOX 1813
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-1813
Mailing Address - Country:US
Mailing Address - Phone:985-492-9100
Mailing Address - Fax:985-492-9102
Practice Address - Street 1:905 CANAL BLVD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4505
Practice Address - Country:US
Practice Address - Phone:985-492-9100
Practice Address - Fax:985-492-9102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07204, MD016897174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty