Provider Demographics
NPI:1598882151
Name:SUGARLAND PEDIATRICS, LLC
Entity Type:Organization
Organization Name:SUGARLAND PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GRETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURGEOIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-448-3737
Mailing Address - Street 1:PO BOX 968
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-0968
Mailing Address - Country:US
Mailing Address - Phone:985-448-3737
Mailing Address - Fax:985-448-3736
Practice Address - Street 1:5642 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-1250
Practice Address - Country:US
Practice Address - Phone:985-853-2273
Practice Address - Fax:985-853-2790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022422208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty