Healthcare Provider Details

I. General information

NPI: 1356253546
Provider Name (Legal Business Name): BRAD MELANCON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5414 BRITTANY DR
BATON ROUGE LA
70808-9139
US

IV. Provider business mailing address

38687 ALDERLY LN
DENHAM SPRINGS LA
70706-0480
US

V. Phone/Fax

Practice location:
  • Phone: 225-526-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: