Provider Demographics
NPI:1780875740
Name:CHACHERE PROVOST MEDICINE, LLC
Entity type:Organization
Organization Name:CHACHERE PROVOST MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PROVOST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-942-2323
Mailing Address - Street 1:3975 I 49 S SERVICE RD
Mailing Address - Street 2:SUITE 205A
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-0775
Mailing Address - Country:US
Mailing Address - Phone:337-942-2323
Mailing Address - Fax:337-942-2626
Practice Address - Street 1:3975 I 49 S SERVICE RD
Practice Address - Street 2:SUITE 205A
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-0775
Practice Address - Country:US
Practice Address - Phone:337-942-2323
Practice Address - Fax:337-942-2626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0701037OtherUNITED HEALTHCARE
160059334OtherRAILROAD MEDICARE
7352418OtherAETNA
LA4389889160OtherBLUE CROSS BLUE SHIELD OF
LA1571831Medicaid
LA5CC55Medicare PIN