=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619257391
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAFAYETTE HEALTH VENTURES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2011
-----------------------------------------------------
Last Update Date | 08/25/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 W SAINT MARY BLVD SUITE 403
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70506-3568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-233-3731
-----------------------------------------------------
Fax | 337-235-6900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 W SAINT MARY BLVD SUITE 403
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70506-3568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-233-3731
-----------------------------------------------------
Fax | 337-235-6900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF PHYSICIAN PRACTICES
-----------------------------------------------------
Name | BRIAN KIRK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 337-289-8951
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 13387R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------