Healthcare Provider Details

I. General information

NPI: 1356973077
Provider Name (Legal Business Name): PHCA HOUMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 CORPORATE DR STE 402
HOUMA LA
70360-2498
US

IV. Provider business mailing address

119 E MAIN ST STE 200
LAFAYETTE LA
70501-6921
US

V. Phone/Fax

Practice location:
  • Phone: 985-400-3019
  • Fax: 985-400-3021
Mailing address:
  • Phone: 214-763-1184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. WAYNE L WILIAMS JR.
Title or Position: CFO
Credential:
Phone: 214-763-1184