MEDICARE: MRS. BOITUMELO PELOKGALE KGOADI RPT

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	174400000X	Specialist	01833F	LA

General Provider Information

NPI Number	:	1740375955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BOITUMELO PELOKGALE KGOADI RPT

Provider Business Mailing Address
First Line	:	121 CRESTHILL DR
Second Line	:
City	:	YOUNGSVILLE
State	:	LA
Zip	:	70592-5656
Country	:	US
Telephone Number	:	337-356-8835
Fax Number	:	337-857-6592

Provider Business Practice Location Address
First Line	:	3021 VEROT SCHOOL ROAD
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-8025
Country	:	US
Telephone Number	:	337-857-6178
Fax Number	:	337-857-6592

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/08/2007

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