Provider Demographics
NPI:1528565942
Name:BORDELON, CHARLOTTE MARTIA
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:MARTIA
Last Name:BORDELON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 CLOVER DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-4710
Mailing Address - Country:US
Mailing Address - Phone:337-215-2613
Mailing Address - Fax:337-990-5077
Practice Address - Street 1:1516 CLOVER DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4710
Practice Address - Country:US
Practice Address - Phone:337-215-2613
Practice Address - Fax:337-990-5077
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA006828053343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA82-4215302Medicaid