1962629212 NPI number — DR ALLEN J HERBERT A MEDICAL CORP

Table of content: (NPI 1962629212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962629212 NPI number — DR ALLEN J HERBERT A MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR ALLEN J HERBERT A MEDICAL CORP
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:
Provider Other Organization Name Type Code:
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:
1962629212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1768
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71166-1768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-677-7450
Provider Business Mailing Address Fax Number:
318-425-5815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 E VAUGHN AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
RUSTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71270-5972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-255-7474
Provider Business Practice Location Address Fax Number:
318-254-5278
Provider Enumeration Date:
04/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HERBERT
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
318-255-7474

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD010285 , 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)

  • Identifier: 1126403 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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