=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831645191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREAUX BRIDGE MM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2016
-----------------------------------------------------
Last Update Date | 08/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1451 E BRIDGE STREET
-----------------------------------------------------
City | BREAUX BRIDGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-456-6851
-----------------------------------------------------
Fax | 337-504-4798
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2851 JOHNSTON ST PMB 299
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70503-3243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-456-6851
-----------------------------------------------------
Fax | 337-504-4798
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MS. ASHLEY HILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 337-781-1630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------