Healthcare Provider Details

I. General information

NPI: 1457751307
Provider Name (Legal Business Name): IMPERIAL HEALTH, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 ELTON RD SUITE H
JENNINGS LA
70546-4100
US

IV. Provider business mailing address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

V. Phone/Fax

Practice location:
  • Phone: 337-246-7200
  • Fax: 337-246-7202
Mailing address:
  • Phone: 337-312-8360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: MR. KEITH BROACH
Title or Position: CEO/PRESIDENT
Credential:
Phone: 337-433-8400