Provider Demographics
NPI:1790854404
Name:MEDSOUTH. LLC
Entity Type:Organization
Organization Name:MEDSOUTH. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLEY
Authorized Official - Middle Name:H
Authorized Official - Last Name:ROUGEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-473-0863
Mailing Address - Street 1:3700 BAYOU RAPIDES RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3601
Mailing Address - Country:US
Mailing Address - Phone:318-473-0863
Mailing Address - Fax:318-473-9889
Practice Address - Street 1:3700 BAYOU RAPIDES RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3601
Practice Address - Country:US
Practice Address - Phone:318-473-0863
Practice Address - Fax:318-473-9889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5F611Medicare ID - Type UnspecifiedPART B PROV. #