Healthcare Provider Details

I. General information

NPI: 1184387177
Provider Name (Legal Business Name): PEDIATRIC CLINIC OF LAFAYETTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 GENEVIEVE DR
LAFAYETTE LA
70503-4811
US

IV. Provider business mailing address

104 GENEVIEVE DR
LAFAYETTE LA
70503-4811
US

V. Phone/Fax

Practice location:
  • Phone: 337-984-0110
  • Fax: 337-981-7210
Mailing address:
  • Phone: 337-984-0110
  • Fax: 337-981-7210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. USHA KRISHNAMOORTHY
Title or Position: BILLING OFFICE
Credential: RHIA, CCS-P
Phone: 337-322-6673