Provider Demographics
NPI:1689126658
Name:BEAUREGARD MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:BEAUREGARD MEDICAL GROUP LLC
Other - Org Name:SOUTH BEAUREGARD MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:VIZINAT
Authorized Official - Suffix:
Authorized Official - Credentials:APRN FNP-C
Authorized Official - Phone:337-405-7778
Mailing Address - Street 1:12186 HIGHWAY 171
Mailing Address - Street 2:
Mailing Address - City:LONGVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70652-4625
Mailing Address - Country:US
Mailing Address - Phone:337-405-7778
Mailing Address - Fax:
Practice Address - Street 1:12186 HIGHWAY 171
Practice Address - Street 2:
Practice Address - City:LONGVILLE
Practice Address - State:LA
Practice Address - Zip Code:70652
Practice Address - Country:US
Practice Address - Phone:337-226-5301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-26
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08501261QP2300X, 261QR1300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2424351Medicaid