Provider Demographics
NPI:1932323292
Name:LANCLOS, RACHELLE T (DT)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:T
Last Name:LANCLOS
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3983 I-49 SOUTH SERVICE ROAD
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570
Mailing Address - Country:US
Mailing Address - Phone:337-948-2125
Mailing Address - Fax:
Practice Address - Street 1:3983 I-49 SOUTH SERVICE ROAD
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570
Practice Address - Country:US
Practice Address - Phone:337-948-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA940133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C217Medicare UPIN