Provider Demographics
NPI:1053315846
Name:HIGHLAND CLINIC, A PROF MED CORP
Entity Type:Organization
Organization Name:HIGHLAND CLINIC, A PROF MED CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-798-4598
Mailing Address - Street 1:1455 E BERT KOUNS LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-798-4500
Mailing Address - Fax:318-798-4555
Practice Address - Street 1:1455 E BERT KOUNS LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5634
Practice Address - Country:US
Practice Address - Phone:318-798-4500
Practice Address - Fax:318-798-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1038300Medicaid
AR108413002Medicaid
TX071428901Medicaid
LA56742Medicare PIN
TX00X702Medicare PIN
LA0438840001Medicare NSC