MEDICARE: THE PSYCHIATRIC MEDICINE INSTITUTE OF LA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1023047776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE PSYCHIATRIC MEDICINE INSTITUTE OF LA LLC

Provider Business Mailing Address
First Line	:	850 KALISTE SALOOM RD
Second Line	:	STE 115
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-4230
Country	:	US
Telephone Number	:	337-264-1991
Fax Number	:	337-264-1993

Provider Business Practice Location Address
First Line	:	850 KALISTE SALOOM RD
Second Line	:	STE 115
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-4230
Country	:	US
Telephone Number	:	337-264-1991
Fax Number	:	337-264-1993

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHARLES HOUMA DIXON BOWERS III
Credential	:	MD
Telephone Number	:	337-264-1991

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	03/31/2008

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