Provider Demographics
NPI:1588014864
Name:ACADIANA LONG TERM CARE LLC
Entity Type:Organization
Organization Name:ACADIANA LONG TERM CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MIRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-232-1802
Mailing Address - Street 1:202 WESTGATE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-2711
Mailing Address - Country:US
Mailing Address - Phone:337-232-1802
Mailing Address - Fax:337-232-1809
Practice Address - Street 1:202 WESTGATE RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-2711
Practice Address - Country:US
Practice Address - Phone:337-232-1802
Practice Address - Fax:337-232-1809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025427207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1576140Medicaid
LA5DE30Medicare PIN