Healthcare Provider Details

I. General information

NPI: 1104014349
Provider Name (Legal Business Name): LOUISIANA KIDNEY UPDATE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 AMBASSADOR CAFFERY PKWY FL 4
LAFAYETTE LA
70508-7265
US

IV. Provider business mailing address

523 BEVERLY DR
LAFAYETTE LA
70503-3113
US

V. Phone/Fax

Practice location:
  • Phone: 337-839-9880
  • Fax:
Mailing address:
  • Phone: 337-234-5541
  • Fax: 337-593-8330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY P BLALOCK
Title or Position: PARTNER/PHYSICIAN
Credential: M.D.
Phone: 337-257-4918