=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679396907
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VCP 2 LOUISIANA PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2024
-----------------------------------------------------
Last Update Date | 02/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 BAYOU PINES EAST DR
-----------------------------------------------------
City | LAKE CHARLES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70601-7184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-328-8346
-----------------------------------------------------
Fax | 706-854-2149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1109 MEDICAL CENTER DR BLDG 1A
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-6633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-328-8346
-----------------------------------------------------
Fax | 706-854-2149
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGIONAL PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | JEWELL HALLIBURTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-888-1256
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------