Healthcare Provider Details

I. General information

NPI: 1538673694
Provider Name (Legal Business Name): ADVANCED PAIN MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6536 LASALLE AVE
BATON ROUGE LA
70806-7318
US

IV. Provider business mailing address

6536 LASALLE AVE
BATON ROUGE LA
70806-7318
US

V. Phone/Fax

Practice location:
  • Phone: 318-278-4292
  • Fax:
Mailing address:
  • Phone: 318-278-4292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLY EATON BOUSSERT
Title or Position: MEMBER
Credential:
Phone: 318-278-4292