Provider Demographics
NPI:1295261519
Name:BRYAN G FRENTZ - A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:BRYAN G FRENTZ - A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-254-9980
Mailing Address - Street 1:203 PRINCETON WOODS LOOP
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6601
Mailing Address - Country:US
Mailing Address - Phone:337-254-9980
Mailing Address - Fax:
Practice Address - Street 1:1151 MARGUERITE ST
Practice Address - Street 2:SUITE 700 B
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1850
Practice Address - Country:US
Practice Address - Phone:985-221-4320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-05
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.024773261QM2500X
332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7633960001OtherMEDICARE NSC