Provider Demographics
NPI:1265784094
Name:THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Entity type:Organization
Organization Name:THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-493-4721
Mailing Address - Street 1:PO BOX 5478
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:985-447-5500
Mailing Address - Fax:
Practice Address - Street 1:602 N ACADIA RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4847
Practice Address - Country:US
Practice Address - Phone:985-447-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-03
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2325060Medicaid
LA257379Medicare PIN