Provider Demographics
NPI:1245215706
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:THE FOOT SURGERY CENTER OF SHREVEPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/PHYSICIAN
Authorized Official - Prefix:DR
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:SUITE 300
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:SUITE 300
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?:Yes
Parent Organization LBN:SOUTHSIDE FOOT CLINIC OF SHREVEPORT INC A PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-07
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA33261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA11026Medicare PIN