Provider Demographics
NPI:1205921442
Name:BOULET MEDICAL CLINIC
Entity type:Organization
Organization Name:BOULET MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOYD
Authorized Official - Middle Name:HONORE
Authorized Official - Last Name:BOULET
Authorized Official - Suffix:JR
Authorized Official - Credentials:GP
Authorized Official - Phone:337-942-6324
Mailing Address - Street 1:8676 HIGHWAY 182
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-5602
Mailing Address - Country:US
Mailing Address - Phone:337-942-6324
Mailing Address - Fax:337-942-8573
Practice Address - Street 1:8676 HIGHWAY 182
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-5602
Practice Address - Country:US
Practice Address - Phone:337-942-6324
Practice Address - Fax:337-942-8573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1090085Medicaid
LA4366078090OtherBLUECROSSBLUESHIELD
LA1090085Medicaid
LA50131Medicare ID - Type Unspecified
LAB62201Medicare UPIN