Healthcare Provider Details

I. General information

NPI: 1023225356
Provider Name (Legal Business Name): LAFAYETTE HEART CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 AMBASSADOR CAFFERY PKWY PROVINCE BUILDING 1
LAFAYETTE LA
70508
US

IV. Provider business mailing address

5000 AMBASSADOR CAFFERY PKWY PROVINCE, BUILDING 1
LAFAYETTE LA
70508
US

V. Phone/Fax

Practice location:
  • Phone: 337-261-0928
  • Fax: 337-233-7773
Mailing address:
  • Phone: 337-261-0928
  • Fax: 337-233-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER T MALLAVARAPA
Title or Position: MD/OWNER
Credential: MD
Phone: 337-261-0928