Provider Demographics
NPI:1922283225
Name:PEDIATRIC GROUP OF ACADIANA, LLC
Entity Type:Organization
Organization Name:PEDIATRIC GROUP OF ACADIANA, LLC
Other - Org Name:ST. MARTINVILLE MATERNAL-CHILD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALEC
Authorized Official - Middle Name:
Authorized Official - Last Name:MOYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-256-5111
Mailing Address - Street 1:401 YOUNGSVILLE HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5173
Mailing Address - Country:US
Mailing Address - Phone:337-330-0031
Mailing Address - Fax:
Practice Address - Street 1:1119 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT MARTINVILLE
Practice Address - State:LA
Practice Address - Zip Code:70582-3513
Practice Address - Country:US
Practice Address - Phone:337-394-7774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10447R174400000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA193885OtherMEDICARE RURAL HEALTH ID
LA1027545Medicaid