Healthcare Provider Details

I. General information

NPI: 1043836166
Provider Name (Legal Business Name): THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 BOWIE RD
THIBODAUX LA
70301-6712
US

IV. Provider business mailing address

PO BOX 5478
THIBODAUX LA
70302-5478
US

V. Phone/Fax

Practice location:
  • Phone: 985-493-4990
  • Fax: 985-493-4991
Mailing address:
  • Phone: 985-435-4831
  • Fax: 985-449-2585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIM LEGENDRE BOUDREAUX
Title or Position: CONTRACT MANAGER
Credential:
Phone: 985-493-4907