Healthcare Provider Details

I. General information

NPI: 1306021357
Provider Name (Legal Business Name): LOUISIANA UROLOGY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 AMBASSADOR CAFFERY PKWY BLD 16
LAFAYETTE LA
70508-6984
US

IV. Provider business mailing address

5000 AMBASSADOR CAFFERY PKWY BLD 16
LAFAYETTE LA
70508-6984
US

V. Phone/Fax

Practice location:
  • Phone: 337-406-8009
  • Fax: 337-406-8010
Mailing address:
  • Phone: 337-406-8009
  • Fax: 337-406-8010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number11767R
License Number StateLA

VIII. Authorized Official

Name: DR. THOMAS J FOREST
Title or Position: PHYSICIAN
Credential: M.D.,
Phone: 337-406-8009