1720574452 NPI number — MR. BORIS TRENT BARTLEY II PLPC

Table of content: FLORENCE NANA KOUCHOU (NPI 1396176467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720574452 NPI number — MR. BORIS TRENT BARTLEY II PLPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARTLEY
Provider First Name:
BORIS
Provider Middle Name:
TRENT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
II
Provider Credential Text:
PLPC
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:
1720574452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4141 COURTLAND WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71006-9723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-294-7569
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2924 KNIGHT ST STE 436
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:
71105-2431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-606-4413
Provider Business Practice Location Address Fax Number:
318-425-9030
Provider Enumeration Date:
07/05/2018

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: 101YP2500X , with the licence number:  10902 , 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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