Healthcare Provider Details

I. General information

NPI: 1952975104
Provider Name (Legal Business Name): GANNON MEDICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 RUE DE BRILLE
NEW IBERIA LA
70563-2169
US

IV. Provider business mailing address

124 KAROLWOOD DR
LAFAYETTE LA
70503-3505
US

V. Phone/Fax

Practice location:
  • Phone: 337-367-1247
  • Fax: 337-365-7496
Mailing address:
  • Phone: 225-718-3764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLEY GANNON
Title or Position: MANAGER
Credential:
Phone: 225-718-3764