Provider Demographics
NPI:1104273978
Name:HANNIBAL, RODERICK
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:HANNIBAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1162 OLIVER RD STE 4
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5757
Mailing Address - Country:US
Mailing Address - Phone:318-340-1535
Mailing Address - Fax:318-340-1539
Practice Address - Street 1:1162 OLIVER RD STE 4
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5757
Practice Address - Country:US
Practice Address - Phone:318-340-1535
Practice Address - Fax:318-340-1539
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator