Healthcare Provider Details

I. General information

NPI: 1780573329
Provider Name (Legal Business Name): THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 N ACADIA RD THIBODAUX REGIONAL CRITICAL CARE
THIBODAUX LA
70301-4823
US

IV. Provider business mailing address

602 N ACADIA RD CONTRACT MANAGEMENT DEPT.
THIBODAUX LA
70301-4823
US

V. Phone/Fax

Practice location:
  • Phone: 985-447-5500
  • Fax: 985-446-5033
Mailing address:
  • Phone: 985-493-4907
  • Fax: 985-449-2585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

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