=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699098491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EUNICE FAMILY PRACTICE, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2010
-----------------------------------------------------
Last Update Date | 03/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3521 HIGHWAY 190 SUITE P
-----------------------------------------------------
City | EUNICE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-457-8040
-----------------------------------------------------
Fax | 337-457-8043
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3521 HIGHWAY 190 SUITE P
-----------------------------------------------------
City | EUNICE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-457-8040
-----------------------------------------------------
Fax | 337-457-8043
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CRAIG MICHAEL MATHERNE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 337-457-8040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number | 14666R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number | 13221R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------