Provider Demographics
NPI:1417085143
Name:C V GUILLERMO JR A PROFESSIONAL MEDICAL CORP
Entity Type:Organization
Organization Name:C V GUILLERMO JR A PROFESSIONAL MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAUDIO
Authorized Official - Middle Name:V
Authorized Official - Last Name:GUILLERMO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:985-532-5092
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:RACELAND
Mailing Address - State:LA
Mailing Address - Zip Code:70394
Mailing Address - Country:US
Mailing Address - Phone:985-532-5092
Mailing Address - Fax:985-532-8044
Practice Address - Street 1:4912 HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:RACELAND
Practice Address - State:LA
Practice Address - Zip Code:70394
Practice Address - Country:US
Practice Address - Phone:985-532-5092
Practice Address - Fax:985-532-8044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03719R208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1574214481OtherBLUE CROSS
LA1124087Medicaid
LA1124087Medicaid
LA50149Medicare ID - Type Unspecified