Healthcare Provider Details

I. General information

NPI: 1750808911
Provider Name (Legal Business Name): ONE TELEMED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 08/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W PINHOOK ROAD BUILDING 3 SUITE 219
LAFAYETTE LA
70503
US

IV. Provider business mailing address

1001 W PINHOOK ROAD BUILDING 3 SUITE 219
LAFAYETTE LA
70503
US

V. Phone/Fax

Practice location:
  • Phone: 337-565-0843
  • Fax: 337-205-4150
Mailing address:
  • Phone: 337-565-0843
  • Fax: 337-205-4150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES EDWARDS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 337-565-0843