Provider Demographics
NPI:1679396907
Name:VCP 2 LOUISIANA PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:VCP 2 LOUISIANA PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEWELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLIBURTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-888-1256
Mailing Address - Street 1:1109 MEDICAL CENTER DR BLDG 1A
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6633
Mailing Address - Country:US
Mailing Address - Phone:866-328-8346
Mailing Address - Fax:706-854-2149
Practice Address - Street 1:750 BAYOU PINES EAST DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7184
Practice Address - Country:US
Practice Address - Phone:866-328-8346
Practice Address - Fax:706-854-2149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-05
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty