MEDICARE: CAVANAUGH FAMILY PRACTICE 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	261QP2300X	Primary Care Clinic/Center	203896	LA

General Provider Information

NPI Number	:	1538446794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAVANAUGH FAMILY PRACTICE LLC

Provider Business Mailing Address
First Line	:	1114 STELLY LN
Second Line	:
City	:	SULPHUR
State	:	LA
Zip	:	70663-5139
Country	:	US
Telephone Number	:	337-527-7087
Fax Number	:	337-527-9831

Provider Business Practice Location Address
First Line	:	1114 STELLY LN
Second Line	:
City	:	SULPHUR
State	:	LA
Zip	:	70663-5139
Country	:	US
Telephone Number	:	337-527-7087
Fax Number	:	337-527-9831

Authorized Official
Title or Position	:	OWNER
Name	:	LACEY MILLETT CAVANAUGH
Credential	:	M.D.
Telephone Number	:	337-527-7087

Provider Enumeration Date	:	11/15/2011
Last Update Date	:	11/15/2011

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Directions to “CAVANAUGH FAMILY PRACTICE LLC ” Practice Location

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