=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467507913
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PELICAN STATE OUTPATIENT CENTER - CARO CLINIC L. L. C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 11/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2304 S BURNSIDE AVE STE 2
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70737-4664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-647-6533
-----------------------------------------------------
Fax | 225-644-7533
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1499
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70707-1499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-647-6533
-----------------------------------------------------
Fax | 225-644-7533
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER OWNER
-----------------------------------------------------
Name | PETER J. MONTEYNE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 225-647-6533
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------