MEDICARE: AMBEAUX PROFESSIONAL MGMT SER 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	207Q00000X	Family Medicine Physician	PA01279	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00664R	OTHER		MC - GROUP #

General Provider Information

NPI Number	:	1699751180
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMBEAUX PROFESSIONAL MGMT SER LLC

Provider Business Mailing Address
First Line	:	PO BOX 2074
Second Line	:
City	:	LIVINGSTON
State	:	TX
Zip	:	77351-2074
Country	:	US
Telephone Number	:	936-328-8944
Fax Number	:	936-328-8945

Provider Business Practice Location Address
First Line	:	604 S WASHINGTON ST
Second Line	:
City	:	LIVINGSTON
State	:	TX
Zip	:	77351-2074
Country	:	US
Telephone Number	:	936-328-8944
Fax Number	:	936-328-8945

Authorized Official
Title or Position	:	PHYSICIAN ASSISTANT SUPERVISOR
Name	:	MR. LOUIS IRVIN AMBEAUX JR.
Credential	:	PA
Telephone Number	:	936-328-8944

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	08/22/2020

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