Provider Demographics
NPI:1215326756
Name:REYNARD C ODENHEIMER MD A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:REYNARD C ODENHEIMER MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAT
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:KERSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-439-5588
Mailing Address - Street 1:816 W BAYOU PINES DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7077
Mailing Address - Country:US
Mailing Address - Phone:337-439-5588
Mailing Address - Fax:337-439-0808
Practice Address - Street 1:816 W BAYOU PINES DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7077
Practice Address - Country:US
Practice Address - Phone:337-439-5588
Practice Address - Fax:337-439-0808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0201592084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1684821Medicaid