Provider Demographics
NPI:1023654712
Name:LOUISIANA CARDIAC VASCULAR AND PULMONARY REHAB LLC
Entity type:Organization
Organization Name:LOUISIANA CARDIAC VASCULAR AND PULMONARY REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAGHOTHAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:PATIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-261-2633
Mailing Address - Street 1:2701 JOHNSTON STREET
Mailing Address - Street 2:STE 100
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503
Mailing Address - Country:US
Mailing Address - Phone:337-261-2633
Mailing Address - Fax:
Practice Address - Street 1:2701 JOHNSTON STREET
Practice Address - Street 2:STE 100
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503
Practice Address - Country:US
Practice Address - Phone:337-261-2633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC3500XNursing Service ProvidersRegistered NurseCardiac RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2701Medicaid