Provider Demographics
NPI:1497348379
Name:THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Entity Type:Organization
Organization Name:THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Other - Org Name:THIBODAUX REGIONAL MULTI-SPECIALTY CLINIC-RACELAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:LEGENDRE
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-493-4907
Mailing Address - Street 1:602 N ACADIA RD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4823
Mailing Address - Country:US
Mailing Address - Phone:985-251-4250
Mailing Address - Fax:985-251-4251
Practice Address - Street 1:4560 HIGHWAY 1 STE 3
Practice Address - Street 2:
Practice Address - City:RACELAND
Practice Address - State:LA
Practice Address - Zip Code:70394-2779
Practice Address - Country:US
Practice Address - Phone:985-435-4831
Practice Address - Fax:985-449-2513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-11
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty