Healthcare Provider Details

I. General information

NPI: 1912967316
Provider Name (Legal Business Name): KENNETH J. CHAMPAGNE, M.D., APMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 DRURY LN
LAFAYETTE LA
70508-5702
US

IV. Provider business mailing address

102 DRURY LN
LAFAYETTE LA
70508-5702
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-0219
  • Fax: 337-233-2418
Mailing address:
  • Phone: 372-233-0219
  • Fax: 337-233-2418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number017238
License Number StateLA

VIII. Authorized Official

Name: MS. SONDRA A. BERNARD
Title or Position: OFFICE MANAGER
Credential: RHIA
Phone: 337-233-0219