Provider Demographics
NPI:1033111240
Name:SOUTHSIDE FOOT CLINIC OF SHREVEPORT, INC. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SOUTHSIDE FOOT CLINIC OF SHREVEPORT, INC. A PROFESSIONAL CORPORATION
Other - Org Name:SOUTHSIDE FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:HAVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:318-687-6266
Mailing Address - Street 1:9308 MANSFIELD RD
Mailing Address - Street 2:STE 100
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3134
Mailing Address - Country:US
Mailing Address - Phone:318-687-6266
Mailing Address - Fax:318-683-1023
Practice Address - Street 1:9308 MANSFIELD RD
Practice Address - Street 2:STE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3134
Practice Address - Country:US
Practice Address - Phone:318-687-6266
Practice Address - Fax:318-683-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5B496213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAU22022Medicare UPIN
LAT19684Medicare UPIN
LA0691670001Medicare NSC