Healthcare Provider Details

I. General information

NPI: 1770359952
Provider Name (Legal Business Name): BENNETT BOUSTANY FONTENOT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 AMBASSADOR CAFFERY PKWY STE 101
LAFAYETTE LA
70508-6984
US

IV. Provider business mailing address

5000 AMBASSADOR CAFFERY PKWY STE 101
LAFAYETTE LA
70508-6984
US

V. Phone/Fax

Practice location:
  • Phone: 504-390-4619
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LAUREN GAST
Title or Position: MANAGER
Credential:
Phone: 985-635-6943