1063644383 NPI number — BRENTWOOD ACQUISITION SHREVEPORT, INC

Table of content: (NPI 1063644383)

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)





Copyright © 2007-2025 www.npivalidator.com