Healthcare Provider Details

I. General information

NPI: 1679396907
Provider Name (Legal Business Name): VCP 2 LOUISIANA PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 BAYOU PINES EAST DR
LAKE CHARLES LA
70601-7184
US

IV. Provider business mailing address

1109 MEDICAL CENTER DR BLDG 1A
AUGUSTA GA
30909-6633
US

V. Phone/Fax

Practice location:
  • Phone: 866-328-8346
  • Fax: 706-854-2149
Mailing address:
  • Phone: 866-328-8346
  • Fax: 706-854-2149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JEWELL HALLIBURTON
Title or Position: REGIONAL PRACTICE ADMINISTRATOR
Credential:
Phone: 706-888-1256