Healthcare Provider Details

I. General information

NPI: 1669802716
Provider Name (Legal Business Name): GHANAMI MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2013
Last Update Date: 11/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 HOSPITAL DR SUITE 410
LAFAYETTE LA
70503-2852
US

IV. Provider business mailing address

155 HOSPITAL DR SUITE 410
LAFAYETTE LA
70503-2852
US

V. Phone/Fax

Practice location:
  • Phone: 337-289-9700
  • Fax: 337-289-9702
Mailing address:
  • Phone: 337-289-9700
  • Fax: 337-289-9702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number205214
License Number StateLA

VIII. Authorized Official

Name: RACHEED JOSEPH GHANAMI
Title or Position: OWNER
Credential: MD
Phone: 337-289-9700