Provider Demographics
NPI:1629474192
Name:THIBODAUX PDHC, LLC
Entity Type:Organization
Organization Name:THIBODAUX PDHC, LLC
Other - Org Name:THIBODAUX PEDIATRIC DAY HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:AMANDA
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-446-1541
Mailing Address - Street 1:124 SUCRE LN
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4214
Mailing Address - Country:US
Mailing Address - Phone:985-446-1541
Mailing Address - Fax:985-446-3864
Practice Address - Street 1:124 SUCRE LN
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4214
Practice Address - Country:US
Practice Address - Phone:985-446-1541
Practice Address - Fax:985-446-3864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-11
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203782237261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care