Healthcare Provider Details

I. General information

NPI: 1831756022
Provider Name (Legal Business Name): JEFFRE RAYBON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12602 COURSEY BLVD
BATON ROUGE LA
70816-4555
US

IV. Provider business mailing address

12602 COURSEY BLVD
BATON ROUGE LA
70816-4555
US

V. Phone/Fax

Practice location:
  • Phone: 225-439-7255
  • Fax:
Mailing address:
  • Phone: 225-439-7255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number884063
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: