Provider Demographics
NPI:1184387177
Name:PEDIATRIC CLINIC OF LAFAYETTE LLC
Entity type:Organization
Organization Name:PEDIATRIC CLINIC OF LAFAYETTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:USHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRISHNAMOORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:RHIA, CCS-P
Authorized Official - Phone:337-322-6673
Mailing Address - Street 1:104 GENEVIEVE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-4811
Mailing Address - Country:US
Mailing Address - Phone:337-984-0110
Mailing Address - Fax:337-981-7210
Practice Address - Street 1:104 GENEVIEVE DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-4811
Practice Address - Country:US
Practice Address - Phone:337-984-0110
Practice Address - Fax:337-981-7210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2138332Medicaid