Healthcare Provider Details

I. General information

NPI: 1184615833
Provider Name (Legal Business Name): GRACE A BANUCHI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MEADOWCREST ST SUITE F
GRETNA LA
70056
US

IV. Provider business mailing address

151 MEADOWCREST ST SUITE F
GRETNA LA
70056
US

V. Phone/Fax

Practice location:
  • Phone: 504-392-9298
  • Fax: 504-392-7047
Mailing address:
  • Phone: 504-392-9298
  • Fax: 504-392-7047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number05544R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: