Provider Demographics
NPI:1255175535
Name:THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Entity type:Organization
Organization Name:THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:LEGENDRE
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-493-4907
Mailing Address - Street 1:602 N. ACADIA RD
Mailing Address - Street 2:ATTN: CONTRACT MNGT DEPT.
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301
Mailing Address - Country:US
Mailing Address - Phone:985-493-4907
Mailing Address - Fax:985-449-2585
Practice Address - Street 1:2031 AUDUBON AVE
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-5073
Practice Address - Country:US
Practice Address - Phone:985-493-4907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-21
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile