Provider Demographics
NPI:1437103124
Name:LACIE ALFONSO MD LLC
Entity Type:Organization
Organization Name:LACIE ALFONSO MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LACIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALFONSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-233-7977
Mailing Address - Street 1:PO BOX 80965
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70598-0965
Mailing Address - Country:US
Mailing Address - Phone:337-233-7977
Mailing Address - Fax:337-233-7978
Practice Address - Street 1:4801 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6917
Practice Address - Country:US
Practice Address - Phone:337-233-7977
Practice Address - Fax:337-233-7978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LADA5900OtherMEDICARE RAILROAD
LA5CH21Medicare ID - Type Unspecified