Provider Demographics
NPI:1366816761
Name:TRAILLE MEDICAL SPECIALTIES, LLC
Entity Type:Organization
Organization Name:TRAILLE MEDICAL SPECIALTIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROEDEMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-678-4471
Mailing Address - Street 1:623 S BURGESS DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-5202
Mailing Address - Country:US
Mailing Address - Phone:225-678-4471
Mailing Address - Fax:225-364-2062
Practice Address - Street 1:606 COLONIAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-6535
Practice Address - Country:US
Practice Address - Phone:225-330-4956
Practice Address - Fax:225-364-2062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA53785261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care