Provider Demographics
NPI:1376009423
Name:TEZENO, GERVIS JR
Entity Type:Individual
Prefix:
First Name:GERVIS
Middle Name:
Last Name:TEZENO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 DAISY LN
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-6733
Mailing Address - Country:US
Mailing Address - Phone:337-418-5334
Mailing Address - Fax:
Practice Address - Street 1:271 DAISY LN
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6733
Practice Address - Country:US
Practice Address - Phone:337-418-5334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)