Provider Demographics
NPI:1174863336
Name:SLSC MEDICAL STAFF
Entity Type:Organization
Organization Name:SLSC MEDICAL STAFF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-841-4486
Mailing Address - Street 1:8711 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6813
Mailing Address - Country:US
Mailing Address - Phone:318-698-8711
Mailing Address - Fax:318-841-4489
Practice Address - Street 1:8711 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6813
Practice Address - Country:US
Practice Address - Phone:318-841-4486
Practice Address - Fax:318-841-4489
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPRING LAKE SURGERY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-26
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical