Provider Demographics
NPI:1659728269
Name:OPUS COALESCE
Entity Type:Organization
Organization Name:OPUS COALESCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMANGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-892-8934
Mailing Address - Street 1:127 HIGHWAY 22 E APT NS
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-9306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:71107 HIGHWAY 21
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7243
Practice Address - Country:US
Practice Address - Phone:985-246-5670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty