=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417712043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOUISIANA VASCULAR LIMB SALVAGE AND CARDIOLOGY APMC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2024
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 WILSON ST
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70503-2439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-456-6523
-----------------------------------------------------
Fax | 337-456-6521
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 81427
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70598-1427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-456-6523
-----------------------------------------------------
Fax | 337-456-6521
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OPERATIONS
-----------------------------------------------------
Name | VICKIE D ABRAHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 337-456-6523
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------