MEDICARE: PEDIATRUST ACADIANA, 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	261QM3000X	Medically Fragile Infants and Children Day Care

General Provider Information

NPI Number	:	1174120612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRUST ACADIANA, LLC

Provider Business Mailing Address
First Line	:	6700 JEFFERSON HWY STE 12
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-8287
Country	:	US
Telephone Number	:	225-252-7633
Fax Number	:	225-304-5466

Provider Business Practice Location Address
First Line	:	331 DOUCET RD
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70503-3447
Country	:	US
Telephone Number	:	225-665-6555
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LEANN CRAIG
Credential	:
Telephone Number	:	225-252-7633

Provider Enumeration Date	:	10/07/2020
Last Update Date	:	10/07/2020

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