Provider Demographics
NPI:1639517550
Name:SOUTHERN REGIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SOUTHERN REGIONAL MEDICAL CORPORATION
Other - Org Name:LEONARD CHABERT MED CTR OUT PT PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PEOPLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-873-4620
Mailing Address - Street 1:8166 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-3404
Mailing Address - Country:US
Mailing Address - Phone:985-873-4141
Mailing Address - Fax:
Practice Address - Street 1:1978 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70363-7055
Practice Address - Country:US
Practice Address - Phone:985-873-1282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN REGIONAL MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1233382Medicaid
1930379OtherNCPDP PROVIDER IDENTIFICATION NUMBER