# PERFUSION VASCULAR VIDALIA LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1356875637
- **Authorized official:** SHAUN R CARPENTER M.D. (OWNER)
- **Authorized official phone:** (985) 892-7070

## Contact information

- **Practice address:** 107 FRONT ST, VIDALIA, LA 71373-2836
- **Practice address phone:** (985) 892-7070
- **Practice address fax:** (985) 892-7017
- **Mailing address:** PO BOX 1089, HAMMOND, LA 70404
- **Mailing address phone:** (985) 892-7070
- **Mailing address fax:** (985) 892-7017

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2086S0129X | Vascular Surgery Physician | — | NULL | Yes |
| 2086S0129X | Vascular Surgery Physician | — | — | Yes |

## Other

- **Enumeration date:** 04/13/2017
- **Last updated:** 06/25/2021