1891168761 NPI number — HIGHLAND CLINIC, A PROF MED CORP

Table of content: (NPI 1891168761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891168761 NPI number — HIGHLAND CLINIC, A PROF MED CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGHLAND CLINIC, A PROF MED CORP
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:
1891168761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1455 E BERT KOUN LOOP
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:
71105-5634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-798-4500
Provider Business Mailing Address Fax Number:
318-798-4555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 E BERT KOUN LOOP
Provider Second Line Business Practice Location Address:
#103
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-5603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-222-8402
Provider Business Practice Location Address Fax Number:
318-222-4556
Provider Enumeration Date:
11/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
318-798-4598

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , 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)

  • Identifier: 1038300 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com