MEDICARE: BEAUREGARD UROLOGY 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	208800000X	Urology Physician

General Provider Information

NPI Number	:	1891124384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEAUREGARD UROLOGY CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 730
Second Line	:
City	:	DERIDDER
State	:	LA
Zip	:	70634-0730
Country	:	US
Telephone Number	:	337-462-7409
Fax Number	:	337-462-7479

Provider Business Practice Location Address
First Line	:	316 W 7TH ST
Second Line	:
City	:	DERIDDER
State	:	LA
Zip	:	70634-4914
Country	:	US
Telephone Number	:	337-462-7409
Fax Number	:	337-462-7479

Authorized Official
Title or Position	:	CFO
Name	:	MR. DARRELL L KINGHAM
Credential	:	CPA
Telephone Number	:	337-462-7409

Provider Enumeration Date	:	11/05/2013
Last Update Date	:	11/03/2016

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