Healthcare Provider Details

I. General information

NPI: 1447713094
Provider Name (Legal Business Name): KOBY LANCLOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 AUDUBON BLVD STE 215-B
LAFAYETTE LA
70503-2676
US

IV. Provider business mailing address

401 AUDUBON BLVD STE 215-B
LAFAYETTE LA
70503-2676
US

V. Phone/Fax

Practice location:
  • Phone: 337-366-1144
  • Fax:
Mailing address:
  • Phone: 337-366-1144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number338353
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: