=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639552334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREVENTIVE COMPLIANCE SOLUTIONS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2015
-----------------------------------------------------
Last Update Date | 06/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1012 PETROLEUM PKWY
-----------------------------------------------------
City | BROUSSARD
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70518-8020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-551-4946
-----------------------------------------------------
Fax | 337-551-4948
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1012 PETROLEUM PKWY
-----------------------------------------------------
City | BROUSSARD
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70518-8020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-551-4946
-----------------------------------------------------
Fax | 337-551-4948
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT - CHIEF MEDICAL OFFICER
-----------------------------------------------------
Name | DR. PRASHANT GUPTA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 337-551-4946
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083P0500X
-----------------------------------------------------
Taxonomy Name | Preventive Medicine/Occupational Environmental Medicine Physician
-----------------------------------------------------
License Number | 201782
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------