1285405159 NPI number — PHILIP BRANDON BROUSSARD I CIT

Table of content: PHILIP BRANDON BROUSSARD I CIT (NPI 1285405159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285405159 NPI number — PHILIP BRANDON BROUSSARD I CIT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUSSARD
Provider First Name:
PHILIP
Provider Middle Name:
BRANDON
Provider Name Prefix Text:
Provider Name Suffix Text:
I
Provider Credential Text:
CIT
Provider Gender Code:
M

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:
1285405159
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7330 FERN AVE STE 1003
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:
71105-4988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-550-5490
Provider Business Mailing Address Fax Number:
318-550-5489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7330 FERN AVE STE 1003
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-4988
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-550-5490
Provider Business Practice Location Address Fax Number:
318-550-5489
Provider Enumeration Date:
01/10/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X , with the licence number:  CIT-5418 , 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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