Provider Demographics
NPI:1790561868
Name:THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Entity Type:Organization
Organization Name:THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:LEGENDRE
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-493-4907
Mailing Address - Street 1:602 NORTH ACADIA ROAD
Mailing Address - Street 2:CONTRACT MANAGEMENT DEPT.
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301
Mailing Address - Country:US
Mailing Address - Phone:985-493-4907
Mailing Address - Fax:
Practice Address - Street 1:3928 HIGHWAY 70 S
Practice Address - Street 2:
Practice Address - City:PIERRE PART
Practice Address - State:LA
Practice Address - Zip Code:70339-4460
Practice Address - Country:US
Practice Address - Phone:985-369-6070
Practice Address - Fax:985-252-1400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty