Healthcare Provider Details

I. General information

NPI: 1407315617
Provider Name (Legal Business Name): KP MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

854 KALISTE SALOOM RD STE C
LAFAYETTE LA
70508-4367
US

IV. Provider business mailing address

854 KALISTE SALOOM RD STE C
LAFAYETTE LA
70508-4367
US

V. Phone/Fax

Practice location:
  • Phone: 337-443-9063
  • Fax: 337-443-9063
Mailing address:
  • Phone: 337-443-9063
  • Fax: 337-443-9067

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 Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TONIA LYNNE SYLVESTER
Title or Position: CLINIC MANAGER
Credential:
Phone: 337-351-5510