Healthcare Provider Details

I. General information

NPI: 1396570511
Provider Name (Legal Business Name): THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N ACADIA RD
THIBODAUX LA
70301-4856
US

IV. Provider business mailing address

602 N ACADIA RD
THIBODAUX LA
70301-4823
US

V. Phone/Fax

Practice location:
  • Phone: 985-493-3034
  • Fax: 985-493-3035
Mailing address:
  • Phone: 985-494-4907
  • Fax: 985-449-2585

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 Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

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