Healthcare Provider Details

I. General information

NPI: 1356123350
Provider Name (Legal Business Name): PEDIATRICS REIMAGINED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 HIGHWAY 190 STE 9
MANDEVILLE LA
70448-3495
US

IV. Provider business mailing address

1901 HIGHWAY 190 STE 9
MANDEVILLE LA
70448-3495
US

V. Phone/Fax

Practice location:
  • Phone: 985-231-4060
  • Fax: 985-353-4460
Mailing address:
  • Phone: 985-231-4060
  • Fax: 985-353-4460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHELLE THEARD
Title or Position: MANAGING MEMBER
Credential: DNP, CPNP-AC
Phone: 504-343-4714