Healthcare Provider Details

I. General information

NPI: 1376716761
Provider Name (Legal Business Name): CONSERVATIVE MEDICAL MANAGEMENT A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 KALISTE SALOOM RD SUITE 202
LAFAYETTE LA
70508-5783
US

IV. Provider business mailing address

1103 KALISTE SALOOM RD SUITE 202
LAFAYETTE LA
70508-5783
US

V. Phone/Fax

Practice location:
  • Phone: 337-269-6335
  • Fax: 337-235-2765
Mailing address:
  • Phone: 337-269-6335
  • Fax: 337-235-2765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberL10009R
License Number StateLA

VIII. Authorized Official

Name: MITZIE B DUHON
Title or Position: OFFICE MANAGER
Credential:
Phone: 337-269-6335