Provider Demographics
NPI:1003139619
Name:VA DIABETIC FOOT SOURCE LLC
Entity Type:Organization
Organization Name:VA DIABETIC FOOT SOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:V
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:318-560-2700
Mailing Address - Street 1:9414 ASHMONT ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-4830
Mailing Address - Country:US
Mailing Address - Phone:318-560-2700
Mailing Address - Fax:
Practice Address - Street 1:9414 ASHMONT ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-4830
Practice Address - Country:US
Practice Address - Phone:318-560-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN121799251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care