Provider Demographics
NPI:1184152340
Name:RICHARD, LETRAINIUMP KIVANTE (BA)
Entity type:Individual
Prefix:MR
First Name:LETRAINIUMP
Middle Name:KIVANTE
Last Name:RICHARD
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 S PIERCE ST UNIT 1305
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-5962
Mailing Address - Country:US
Mailing Address - Phone:337-849-5404
Mailing Address - Fax:
Practice Address - Street 1:7830 COLAPISSA ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70125
Practice Address - Country:US
Practice Address - Phone:337-849-5404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1438641Medicaid