Provider Demographics
NPI:1396911558
Name:PROGRESSIVE ACUTE CARE PHYSICIAN SERVICES DAUTERIVE LLC
Entity type:Organization
Organization Name:PROGRESSIVE ACUTE CARE PHYSICIAN SERVICES DAUTERIVE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-624-7401
Mailing Address - Street 1:PO BOX 11539
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70562-1539
Mailing Address - Country:US
Mailing Address - Phone:337-369-3481
Mailing Address - Fax:337-365-8455
Practice Address - Street 1:1100 ANDRE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2159
Practice Address - Country:US
Practice Address - Phone:337-369-9309
Practice Address - Fax:337-365-8455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1321583Medicaid
LA1321583Medicaid