Healthcare Provider Details

I. General information

NPI: 1588014864
Provider Name (Legal Business Name): ACADIANA LONG TERM CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 WESTGATE RD
LAFAYETTE LA
70506-2711
US

IV. Provider business mailing address

202 WESTGATE RD
LAFAYETTE LA
70506-2711
US

V. Phone/Fax

Practice location:
  • Phone: 337-232-1802
  • Fax: 337-232-1809
Mailing address:
  • Phone: 337-232-1802
  • Fax: 337-232-1809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number025427
License Number StateLA

VIII. Authorized Official

Name: DR. GEOFFREY A MIRE
Title or Position: CEO
Credential: MD
Phone: 337-232-1802