Provider Demographics
NPI:1649215765
Name:BROUSSARD SURGERY INSTITUTE, INC.
Entity Type:Organization
Organization Name:BROUSSARD SURGERY INSTITUTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANICA
Authorized Official - Middle Name:G
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-387-2015
Mailing Address - Street 1:1250 PECANLAND RD
Mailing Address - Street 2:SUITE E-1
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-7011
Mailing Address - Country:US
Mailing Address - Phone:318-387-2015
Mailing Address - Fax:318-387-2097
Practice Address - Street 1:1250 PECANLAND RD
Practice Address - Street 2:SUITE E-1
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-7011
Practice Address - Country:US
Practice Address - Phone:318-387-2015
Practice Address - Fax:318-387-2097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA124261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1925276Medicaid
LA1925276Medicaid