=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023047776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE PSYCHIATRIC MEDICINE INSTITUTE OF LA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2006
-----------------------------------------------------
Last Update Date | 03/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 KALISTE SALOOM RD STE 115
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70508-4230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-264-1991
-----------------------------------------------------
Fax | 337-264-1993
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 850 KALISTE SALOOM RD STE 115
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70508-4230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-264-1991
-----------------------------------------------------
Fax | 337-264-1993
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHARLES HOUMA DIXON BOWERS III
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 337-264-1991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------