Individual
MR. BRENT DAVID BOUDREAUX
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
ATC
Contact information
Practice address
104 DENETTE DR, DUSON, LA 70529-3750
(337) 344-3400
Mailing address
104 DENETTE DR, DUSON, LA 70529-3750
(337) 344-3400
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
ATH.J00109
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
069102490
BOC
—
01
—
ATH.J00109
LA STATE BOARD OF MEDICAL EXAMINERS
LA
Enumeration date
05/17/2007
Last updated
01/10/2021
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