Provider Demographics
NPI:1770007684
Name:SURGICAL ASSISTANTS OF ACADIANA, LLC
Entity Type:Organization
Organization Name:SURGICAL ASSISTANTS OF ACADIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE FIRST ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:FALLON
Authorized Official - Middle Name:ALIESHA
Authorized Official - Last Name:FUNDERBURK
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN, CNOR, RNFA
Authorized Official - Phone:318-218-0515
Mailing Address - Street 1:219 RUE DE FREJUS
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-4993
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 KALISTE SALOOM RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5705
Practice Address - Country:US
Practice Address - Phone:337-769-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN105855163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Single Specialty