Provider Demographics
NPI:1578233136
Name:LEBLANC, JEREMY ROMAINE
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ROMAINE
Last Name:LEBLANC
Suffix:
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 1:338 RAGLE RD
Mailing Address - Street 2:
Mailing Address - City:LONGVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70652-3302
Mailing Address - Country:US
Mailing Address - Phone:346-245-3509
Mailing Address - Fax:
Practice Address - Street 1:338 RAGLE RD
Practice Address - Street 2:
Practice Address - City:LONGVILLE
Practice Address - State:LA
Practice Address - Zip Code:70652-3302
Practice Address - Country:US
Practice Address - Phone:346-245-3509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA84-3415748Medicaid