Healthcare Provider Details

I. General information

NPI: 1023654712
Provider Name (Legal Business Name): LOUISIANA CARDIAC VASCULAR AND PULMONARY REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 JOHNSTON STREET STE 100
LAFAYETTE LA
70503
US

IV. Provider business mailing address

2701 JOHNSTON STREET STE 100
LAFAYETTE LA
70503
US

V. Phone/Fax

Practice location:
  • Phone: 337-261-2633
  • Fax:
Mailing address:
  • Phone: 337-261-2633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC3500X
TaxonomyCardiac Rehabilitation Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: RAGHOTHAM R PATIOLA
Title or Position: CEO
Credential: MD
Phone: 337-261-2633