Provider Demographics
NPI:1689224321
Name:THIBODEAUX MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:THIBODEAUX MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:THIBODEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:337-324-8060
Mailing Address - Street 1:1303 HORRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70668-4531
Mailing Address - Country:US
Mailing Address - Phone:337-324-8060
Mailing Address - Fax:337-324-8061
Practice Address - Street 1:1303 HORRIDGE ST
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:LA
Practice Address - Zip Code:70668-4531
Practice Address - Country:US
Practice Address - Phone:337-324-8060
Practice Address - Fax:337-324-8061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-15
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty