Healthcare Provider Details

I. General information

NPI: 1477398956
Provider Name (Legal Business Name): OCCUPATIONAL & INTEGRATIVE MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 SOUTHPARK RD STE B
LAFAYETTE LA
70508-3611
US

IV. Provider business mailing address

221 SOUTHPARK RD STE B
LAFAYETTE LA
70508-3611
US

V. Phone/Fax

Practice location:
  • Phone: 337-534-0420
  • Fax: 337-806-9576
Mailing address:
  • Phone: 337-534-0420
  • Fax: 337-806-9576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. DONNA B WILSON
Title or Position: NURSE PRACTITIONER
Credential: FNP-C
Phone: 337-534-0420