Healthcare Provider Details

I. General information

NPI: 1578360327
Provider Name (Legal Business Name): THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N ACADIA RD STE 207
THIBODAUX LA
70301-4897
US

IV. Provider business mailing address

PO BOX 669400
DALLAS TX
75266-9490
US

V. Phone/Fax

Practice location:
  • Phone: 985-446-1763
  • Fax: 985-446-9813
Mailing address:
  • Phone: 985-493-4907
  • Fax: 985-449-2585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

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