1194749614 NPI number — COMPLETE VITAL CARE, INC.

Table of content: (NPI 1194749614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194749614 NPI number — COMPLETE VITAL CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPLETE VITAL CARE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COMPLETE VITAL CARE - SHREVEPORT
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194749614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5047
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39302-5047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-447-4095
Provider Business Mailing Address Fax Number:
601-482-7490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2530 BERT KOUNS INDUSTRIAL LOOP
Provider Second Line Business Practice Location Address:
STE 116
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71118-3132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-686-9995
Provider Business Practice Location Address Fax Number:
318-686-9997
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GARDINER
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
318-686-9995

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  4863 IR , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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