Provider Demographics
NPI:1699751180
Name:AMBEAUX PROFESSIONAL MGMT SER LLC
Entity type:Organization
Organization Name:AMBEAUX PROFESSIONAL MGMT SER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:IRVIN
Authorized Official - Last Name:AMBEAUX
Authorized Official - Suffix:JR
Authorized Official - Credentials:PA
Authorized Official - Phone:936-328-8944
Mailing Address - Street 1:PO BOX 2074
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-2074
Mailing Address - Country:US
Mailing Address - Phone:936-328-8944
Mailing Address - Fax:936-328-8945
Practice Address - Street 1:604 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-2074
Practice Address - Country:US
Practice Address - Phone:936-328-8944
Practice Address - Fax:936-328-8945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01279207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00664ROtherMC - GROUP #
S39826Medicare UPIN
TX8N263Medicare ID - Type Unspecified