Individual
JODY MACK BROUSSARD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
494 OTTO FRANKLIN RD, DERIDDER, LA 70634-6404
(337) 396-1312
(337) 462-0283
Mailing address
494 OTTO FRANKLIN RD, DERIDDER, LA 70634-6404
(337) 396-1312
(337) 462-0283
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
005855942
LA
Other
Enumeration date
02/15/2018
Last updated
02/15/2018
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