Healthcare Provider Details

I. General information

NPI: 1174344972
Provider Name (Legal Business Name): TAYLEM BREAUX BS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 W PINHOOK RD STE 303
LAFAYETTE LA
70508-3735
US

IV. Provider business mailing address

111 EDIE ANN DR APT 143
LAFAYETTE LA
70508-5365
US

V. Phone/Fax

Practice location:
  • Phone: 337-534-4214
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: