MEDICARE: LANCE BOURGOYNE

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	013969	LA

General Provider Information

NPI Number	:	1568059590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANCE BOURGOYNE

Provider Business Mailing Address
First Line	:	5131 ODONOVAN DR STE 402
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-4792
Country	:	US
Telephone Number	:	225-765-8140
Fax Number	:	225-374-0271

Provider Business Practice Location Address
First Line	:	5131 ODONOVAN DR STE 402
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-4792
Country	:	US
Telephone Number	:	225-765-8140
Fax Number	:	225-374-0271

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2020
Last Update Date	:	12/23/2020

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Directions to “ LANCE BOURGOYNE ” Practice Location

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