Healthcare Provider Details

I. General information

NPI: 1336607381
Provider Name (Legal Business Name): INTEGRATED CARE PROFESSIONALS OF LOUSIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 LONEWA ROAD
MONROE LA
71203-2028
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 501-492-0099
  • Fax: 479-968-1673
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RODNEY THOMASON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 501-406-6180