Healthcare Provider Details

I. General information

NPI: 1952622664
Provider Name (Legal Business Name): CCP MEDICAL MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 FOURPARK RD SUITE C
LAFAYETTE LA
70507-2481
US

IV. Provider business mailing address

213 FOURPARK RD SUITE C
LAFAYETTE LA
70507-2481
US

V. Phone/Fax

Practice location:
  • Phone: 337-896-6440
  • Fax: 337-896-6441
Mailing address:
  • Phone: 337-896-6400
  • Fax: 337-896-6441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GROVER PHIPPS
Title or Position: MANAGER
Credential:
Phone: 337-896-6400