Healthcare Provider Details

I. General information

NPI: 1083043806
Provider Name (Legal Business Name): BEAUREGARD SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W 6TH ST
DERIDDER LA
70634-4902
US

IV. Provider business mailing address

PO BOX 730
DERIDDER LA
70634-0730
US

V. Phone/Fax

Practice location:
  • Phone: 337-462-7409
  • Fax: 337-462-7479
Mailing address:
  • Phone: 337-462-7409
  • Fax: 337-462-7479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DARRELL L KINGHAM
Title or Position: CFO
Credential: CPA
Phone: 337-462-7409