Provider Demographics
NPI:1689065880
Name:TEBAULT, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TEBAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29561
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70189-0561
Mailing Address - Country:US
Mailing Address - Phone:504-221-9531
Mailing Address - Fax:
Practice Address - Street 1:11650 WEST BARRINGTON DR
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70128
Practice Address - Country:US
Practice Address - Phone:504-221-9531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier