Healthcare Provider Details

I. General information

NPI: 1992005532
Provider Name (Legal Business Name): BEAUREGARD PEDIATRIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2010
Last Update Date: 10/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S PINE ST
DERIDDER LA
70634-4942
US

IV. Provider business mailing address

PO BOX 730
DERIDDER LA
70634-0730
US

V. Phone/Fax

Practice location:
  • Phone: 337-462-7106
  • Fax: 337-462-7479
Mailing address:
  • Phone: 337-462-7106
  • Fax: 337-462-7479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. THEODORE J. BADGER JR.
Title or Position: CEO
Credential:
Phone: 337-462-7105