Healthcare Provider Details

I. General information

NPI: 1134440514
Provider Name (Legal Business Name): SRC INTERNATIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2010
Last Update Date: 06/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 BANKS AVE
LAFAYETTE LA
70506-1988
US

IV. Provider business mailing address

509 CAMELLIA DR
LAFAYETTE LA
70503-4701
US

V. Phone/Fax

Practice location:
  • Phone: 337-504-3596
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name: MS. RACHEL COOPER
Title or Position: MEMBER
Credential:
Phone: 337-504-3596