Provider Demographics
NPI:1295272623
Name:EXOTIC EXPRESSIONS INC.
Entity type:Organization
Organization Name:EXOTIC EXPRESSIONS INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:MADALYN
Authorized Official - Last Name:WILTZ
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED
Authorized Official - Phone:337-376-0473
Mailing Address - Street 1:729 CECILE BLVD
Mailing Address - Street 2:BLDG A- 1
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-5707
Mailing Address - Country:US
Mailing Address - Phone:337-376-0473
Mailing Address - Fax:
Practice Address - Street 1:729 CECILE BLVD
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-5707
Practice Address - Country:US
Practice Address - Phone:337-376-0473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11041986302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization