Provider Demographics
NPI:1780814756
Name:BEAUREGARD PHYSICIAN GROUP, LLC
Entity Type:Organization
Organization Name:BEAUREGARD PHYSICIAN GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:KINGHAM
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:337-462-7111
Mailing Address - Street 1:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-0730
Mailing Address - Country:US
Mailing Address - Phone:337-462-7106
Mailing Address - Fax:337-462-7479
Practice Address - Street 1:600 S PINE ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4942
Practice Address - Country:US
Practice Address - Phone:337-462-7106
Practice Address - Fax:337-462-7479
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST LOUISIANA HEALTH SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-23
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.09850R207X00000X
LA261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty