1750672390 NPI number — THERAPEUTIC MEDICAL & PSYCHIATRIC SERVICES LLC.

Table of content: (NPI 1750672390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750672390 NPI number — THERAPEUTIC MEDICAL & PSYCHIATRIC SERVICES LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERAPEUTIC MEDICAL & PSYCHIATRIC SERVICES 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:
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:
1750672390
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 WINTERPARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71292-1106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-396-9712
Provider Business Mailing Address Fax Number:
180-051-8423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 STUBBS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71292-1106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-396-9712
Provider Business Practice Location Address Fax Number:
180-051-8423
Provider Enumeration Date:
05/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PRIVITOR DAVIS
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
PRIVITOR
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
318-816-5116

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  APO5002 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000000000000 . This is a "PRIVATE INSURANCE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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