Healthcare Provider Details

I. General information

NPI: 1336308022
Provider Name (Legal Business Name): PHC-OPELOUSAS LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 09/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3983 I 49 S SERVICE RD
OPELOUSAS LA
70570-0758
US

IV. Provider business mailing address

3983 I 49 S SERVICE RD
OPELOUSAS LA
70570-0758
US

V. Phone/Fax

Practice location:
  • Phone: 337-948-2107
  • Fax: 337-948-2173
Mailing address:
  • Phone: 337-948-2107
  • Fax: 337-948-2173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: MR. WILLIAM M. GRACEY
Title or Position: CHIEF OPERATING OFFICER
Credential: COO
Phone: 615-372-8500