1063644383 NPI number — BRENTWOOD ACQUISITION SHREVEPORT, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063644383 NPI number — BRENTWOOD ACQUISITION SHREVEPORT, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRENTWOOD ACQUISITION SHREVEPORT, 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:
Provider Other Organization Name Type Code:
6
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:
1063644383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1002 HIGHLAND AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71101-4143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-222-6226
Provider Business Mailing Address Fax Number:
318-222-6227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 HIGHLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71101-4143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-222-6226
Provider Business Practice Location Address Fax Number:
318-222-6227
Provider Enumeration Date:
08/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BURNS
Authorized Official First Name:
JODI
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
318-222-6260

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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