Healthcare Provider Details

I. General information

NPI: 1427325364
Provider Name (Legal Business Name): KENNETH L. ODINET MD, ASC-LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2011
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BEAULLIEU DR BUILDING 6
LAFAYETTE LA
70508-7230
US

IV. Provider business mailing address

200 BEAULLIEU DR BUILDING 6
LAFAYETTE LA
70508-7230
US

V. Phone/Fax

Practice location:
  • Phone: 337-234-8648
  • Fax: 337-233-0244
Mailing address:
  • Phone: 337-234-8648
  • Fax: 337-233-0244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number177
License Number StateLA

VIII. Authorized Official

Name: KENNETH L ODINET
Title or Position: OWNER
Credential: M.D.
Phone: 337-234-8648