Provider Demographics
NPI:1093963878
Name:SNELLS LIMBS & BRACES OF SHREVEPORT LLC
Entity Type:Organization
Organization Name:SNELLS LIMBS & BRACES OF SHREVEPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:N
Authorized Official - Last Name:MASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:318-424-4167
Mailing Address - Street 1:1833 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4611
Mailing Address - Country:US
Mailing Address - Phone:318-424-4167
Mailing Address - Fax:
Practice Address - Street 1:8730 YOUREE DR
Practice Address - Street 2:BUILDING A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2518
Practice Address - Country:US
Practice Address - Phone:318-795-0953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0270680004Medicare NSC