Healthcare Provider Details

I. General information

NPI: 1255596490
Provider Name (Legal Business Name): ORTHOPAEDIC RECONSTRUCTIVE SUB-SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 WAYNE GILMORE CIR SUITE 250-A
OPELOUSAS LA
70570-6405
US

IV. Provider business mailing address

1233 WAYNE GILMORE CIR SUITE 250-A
OPELOUSAS LA
70570-6405
US

V. Phone/Fax

Practice location:
  • Phone: 337-948-8556
  • Fax: 337-948-6881
Mailing address:
  • Phone: 337-948-8556
  • Fax: 337-948-6881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number200825
License Number StateLA

VIII. Authorized Official

Name: DR. PAUL E FENN
Title or Position: OWNER / OPERATOR
Credential: MD
Phone: 337-948-8556