1396774451 NPI number — OVERTON BROOKS VAMC

Table of content: (NPI 1396774451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396774451 NPI number — OVERTON BROOKS VAMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OVERTON BROOKS VAMC
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:
1396774451
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 E STONER AVE
Provider Second Line Business Mailing Address:
117
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71101-4243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-424-6014
Provider Business Mailing Address Fax Number:
318-429-5727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 E STONER AVE
Provider Second Line Business Practice Location Address:
117
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71101-4243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-424-6014
Provider Business Practice Location Address Fax Number:
318-429-5727
Provider Enumeration Date:
07/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NGUYEN
Authorized Official First Name:
NGOC
Authorized Official Middle Name:
XUAN
Authorized Official Title or Position:
CHIEF OF SERVICE
Authorized Official Telephone Number:
318-424-6014

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  J 3173 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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