Healthcare Provider Details

I. General information

NPI: 1437103124
Provider Name (Legal Business Name): LACIE ALFONSO MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6917
US

IV. Provider business mailing address

PO BOX 80965
LAFAYETTE LA
70598-0965
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-7977
  • Fax: 337-233-7978
Mailing address:
  • Phone: 337-233-7977
  • Fax: 337-233-7978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: DR. LACIE A ALFONSO
Title or Position: DIRECTOR
Credential: MD
Phone: 337-233-7977