Provider Demographics
NPI:1346890423
Name:LA PETITE PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:LA PETITE PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GENEVA
Authorized Official - Middle Name:MARIE GUIDRY
Authorized Official - Last Name:LEJEUNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-366-8616
Mailing Address - Street 1:200 BEAULLIEU DR STE 7
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-7230
Mailing Address - Country:US
Mailing Address - Phone:337-366-8616
Mailing Address - Fax:337-366-8133
Practice Address - Street 1:200 BEAULLIEU DR STE 7
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7230
Practice Address - Country:US
Practice Address - Phone:337-366-8616
Practice Address - Fax:337-366-8133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2149270Medicaid
LA2116436Medicaid