Provider Demographics
NPI:1063644383
Name:BRENTWOOD ACQUISITION SHREVEPORT, INC
Entity Type:Organization
Organization Name:BRENTWOOD ACQUISITION SHREVEPORT, INC
Other - Org Name:BRENTWOOD OUTPATIENT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-222-6260
Mailing Address - Street 1:1002 HIGHLAND AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4143
Mailing Address - Country:US
Mailing Address - Phone:318-222-6226
Mailing Address - Fax:318-222-6227
Practice Address - Street 1:1002 HIGHLAND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4143
Practice Address - Country:US
Practice Address - Phone:318-222-6226
Practice Address - Fax:318-222-6227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty