Healthcare Provider Details

I. General information

NPI: 1689841595
Provider Name (Legal Business Name): MARY G BREAUX CST-CFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 CORPORATE DR
HOUMA LA
70360-2768
US

IV. Provider business mailing address

190 TEXAS ST
RACELAND LA
70394-2942
US

V. Phone/Fax

Practice location:
  • Phone: 985-853-1390
  • Fax:
Mailing address:
  • Phone: 985-537-4665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: