Provider Demographics
NPI:1265762025
Name:MOBILE X-RAY OF LOUISIANA, LLC
Entity type:Organization
Organization Name:MOBILE X-RAY OF LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-412-6702
Mailing Address - Street 1:910 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2450
Mailing Address - Country:US
Mailing Address - Phone:337-412-6702
Mailing Address - Fax:
Practice Address - Street 1:1021 COOLIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2435
Practice Address - Country:US
Practice Address - Phone:337-412-6702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QR0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0207XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile Mammography