Provider Demographics
NPI:1851532964
Name:THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Entity Type:Organization
Organization Name:THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Other - Org Name:THIBODAUX REGIONAL HEART & VASCULAR CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACT MANAGER
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:PO BOX 5478
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:985-447-5500
Mailing Address - Fax:
Practice Address - Street 1:604 N ACADIA RD
Practice Address - Street 2:SUITE 409
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4897
Practice Address - Country:US
Practice Address - Phone:985-447-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1800856Medicaid
LA1800856Medicaid