1124067145 NPI number — MMO OF SHREVEPORT, LLC

Table of content: (NPI 1124067145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124067145 NPI number — MMO OF SHREVEPORT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MMO OF SHREVEPORT, LLC
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:
ANTARES BEHAVIORAL HEALTH, LLC
Provider Other Organization Name Type Code:
4
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:
1124067145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
728 NORTH BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70802-5724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-293-6774
Provider Business Mailing Address Fax Number:
225-291-9299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3341 YOUREE DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-2149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-688-6228
Provider Business Practice Location Address Fax Number:
318-688-6466
Provider Enumeration Date:
06/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
225-293-6774

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , 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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