Healthcare Provider Details

I. General information

NPI: 1821416256
Provider Name (Legal Business Name): SUPERIOR BROCAGE HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7843 BAJA DR
BATON ROUGE LA
70811-7735
US

IV. Provider business mailing address

7843 BAJA DR
BATON ROUGE LA
70811-7735
US

V. Phone/Fax

Practice location:
  • Phone: 225-328-9051
  • Fax:
Mailing address:
  • Phone: 225-328-9051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JERQUAN BROWN
Title or Position: OWNER
Credential:
Phone: 225-328-9051