Provider Demographics
NPI:1790861953
Name:CHAMPAGNE, CARROLL MARC JR (LPN)
Entity type:Individual
Prefix:MR
First Name:CARROLL
Middle Name:MARC
Last Name:CHAMPAGNE
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2747 HIGHWAY 28 E
Mailing Address - Street 2:APT 306
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-5700
Mailing Address - Country:US
Mailing Address - Phone:318-449-9615
Mailing Address - Fax:
Practice Address - Street 1:UNIT 6, MEADOW LANE
Practice Address - Street 2:CENTRAL LOUISIANA STATE HOSPITAL
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360
Practice Address - Country:US
Practice Address - Phone:318-484-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA850513164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse