Healthcare Provider Details

I. General information

NPI: 1437281367
Provider Name (Legal Business Name): PELVIC HEALTH AND MENOPAUSE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E VAUGHN AVE SUITE 201
RUSTON LA
71270-5972
US

IV. Provider business mailing address

411 E VAUGHN AVE SUITE 201
RUSTON LA
71270-5972
US

V. Phone/Fax

Practice location:
  • Phone: 318-255-3223
  • Fax: 318-255-3181
Mailing address:
  • Phone: 318-255-3223
  • Fax: 318-255-3181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD.201086
License Number StateLA

VIII. Authorized Official

Name: NATHAN WAYNE GOODYEAR
Title or Position: DOCTOR
Credential: M.D.
Phone: 318-255-3223