Healthcare Provider Details

I. General information

NPI: 1295069490
Provider Name (Legal Business Name): THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 N ACADIA RD FL 3
THIBODAUX LA
70301-4847
US

IV. Provider business mailing address

PO BOX 5478
THIBODAUX LA
70302-5478
US

V. Phone/Fax

Practice location:
  • Phone: 985-493-4346
  • Fax: 985-449-2560
Mailing address:
  • Phone: 985-493-4511
  • Fax: 985-449-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

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