Healthcare Provider Details

I. General information

NPI: 1295309029
Provider Name (Legal Business Name): TRPP-ACO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 N. ACADIA ROAD
THIBODAUX LA
70301
US

IV. Provider business mailing address

602 N. ACADIA ROAD
THIBODAUX LA
70301
US

V. Phone/Fax

Practice location:
  • Phone: 985-493-4907
  • Fax: 985-449-2585
Mailing address:
  • Phone: 985-493-4907
  • Fax: 985-493-2585

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 Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM LEGENDRE BOUDREAUX
Title or Position: EXECUTIVE DIRECTOR
Credential: MBA
Phone: 985-449-2585