Healthcare Provider Details

I. General information

NPI: 1790561868
Provider Name (Legal Business Name): THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3928 HIGHWAY 70 S
PIERRE PART LA
70339-4460
US

IV. Provider business mailing address

602 NORTH ACADIA ROAD CONTRACT MANAGEMENT DEPT.
THIBODAUX LA
70301
US

V. Phone/Fax

Practice location:
  • Phone: 985-369-6070
  • Fax: 985-252-1400
Mailing address:
  • Phone: 985-493-4907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KIM LEGENDRE BOUDREAUX
Title or Position: DIRECTOR OF CONTRACTING
Credential:
Phone: 985-493-4907