Healthcare Provider Details

I. General information

NPI: 1134328966
Provider Name (Legal Business Name): L GLEN MIRE MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 DULLES DR
LAFAYETTE LA
70506-3008
US

IV. Provider business mailing address

PO BOX 61950
LAFAYETTE LA
70596-1950
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-0305
  • Fax:
Mailing address:
  • Phone: 337-981-0305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number012202
License Number StateLA

VIII. Authorized Official

Name: DR. LOUIS GLEN MIRE
Title or Position: OWNER
Credential: MD
Phone: 337-981-0305