Healthcare Provider Details

I. General information

NPI: 1639118078
Provider Name (Legal Business Name): ST MICHAEL PFU LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 N DIVISION ST
DEQUINCY LA
70633-3129
US

IV. Provider business mailing address

PO BOX 1219
DEQUINCY LA
70633-1219
US

V. Phone/Fax

Practice location:
  • Phone: 337-786-2466
  • Fax: 337-786-6266
Mailing address:
  • Phone: 337-786-2466
  • Fax: 337-786-6266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number857
License Number StateLA

VIII. Authorized Official

Name: SCOTT BROUSSARD
Title or Position: CPA
Credential:
Phone: 337-639-2934