MEDICARE: PELVIC HEALTH AND MENOPAUSE CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	MD.201086	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	33779	OTHER	LA	CONTROLLED DRUG NUMBER
2	MD.201086	OTHER	LA	STATE LICENSE NUMBER
3	1538166970	OTHER		NPI

General Provider Information

NPI Number	:	1437281367
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PELVIC HEALTH AND MENOPAUSE CENTER LLC

Provider Business Mailing Address
First Line	:	411 E VAUGHN AVE
Second Line	:	SUITE 201
City	:	RUSTON
State	:	LA
Zip	:	71270-5972
Country	:	US
Telephone Number	:	318-255-3223
Fax Number	:	318-255-3181

Provider Business Practice Location Address
First Line	:	411 E VAUGHN AVE
Second Line	:	SUITE 201
City	:	RUSTON
State	:	LA
Zip	:	71270-5972
Country	:	US
Telephone Number	:	318-255-3223
Fax Number	:	318-255-3181

Authorized Official
Title or Position	:	DOCTOR
Name	:	NATHAN WAYNE GOODYEAR
Credential	:	M.D.
Telephone Number	:	318-255-3223

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	03/07/2023

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