Healthcare Provider Details

I. General information

NPI: 1710063391
Provider Name (Legal Business Name): GRAFTON DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 BAYOU GARDENS BLVD
HOUMA LA
70364-1434
US

IV. Provider business mailing address

327 BAYOU GARDENS BLVD
HOUMA LA
70364-1434
US

V. Phone/Fax

Practice location:
  • Phone: 985-876-5000
  • Fax: 985-876-5280
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number022623
License Number StateLA

VIII. Authorized Official

Name: ANN BOURGEOIS
Title or Position: OFF MGR
Credential:
Phone: 978-876-5000