Healthcare Provider Details

I. General information

NPI: 1477870053
Provider Name (Legal Business Name): BACK TO THE REAL WORLD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2010
Last Update Date: 04/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 RUE BEAUREGARD STE 100
LAFAYETTE LA
70508-3285
US

IV. Provider business mailing address

234 RUE BEAUREGARD STE 100
LAFAYETTE LA
70508-3285
US

V. Phone/Fax

Practice location:
  • Phone: 337-593-0830
  • Fax: 337-593-0122
Mailing address:
  • Phone: 337-593-0830
  • Fax: 337-593-0122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number11569R
License Number StateLA

VIII. Authorized Official

Name: MRS. MELISSA M GAD
Title or Position: GENERAL PARTNER
Credential: APRN
Phone: 337-593-0830