Provider Demographics
NPI:1265675029
Name:MARTIN LUTHER KING HEALTH CENTER
Entity Type:Organization
Organization Name:MARTIN LUTHER KING HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:M
Authorized Official - Last Name:MENTESANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-227-2912
Mailing Address - Street 1:1233 SPRAGUE ST.
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-227-2912
Mailing Address - Fax:318-227-8105
Practice Address - Street 1:1233 SPRAGUE ST.
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-227-2912
Practice Address - Fax:318-227-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
LA2441-CH333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No333600000XSuppliersPharmacy