=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679126510
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC GROUP OF ACADIANA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2019
-----------------------------------------------------
Last Update Date | 08/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1307 CROWLEY RAYNE HWY STE C
-----------------------------------------------------
City | CROWLEY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70526-8210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-250-4710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 302 HACKER ST
-----------------------------------------------------
City | NEW IBERIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70560-4508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-330-2576
-----------------------------------------------------
Fax | 337-417-9909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | ANTOINETTE RABENALDT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 337-608-8988
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------