Healthcare Provider Details

I. General information

NPI: 1215743216
Provider Name (Legal Business Name): QUINCY BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2590 HIGHWAY 1
THIBODAUX LA
70301-5843
US

IV. Provider business mailing address

2555 HIGHWAY 1
RACELAND LA
70394-3646
US

V. Phone/Fax

Practice location:
  • Phone: 985-313-1093
  • Fax: 985-313-1093
Mailing address:
  • Phone: 985-803-5016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPLC11396
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: