Provider Demographics
NPI:1275835571
Name:VELOCITY MD LLC
Entity Type:Organization
Organization Name:VELOCITY MD LLC
Other - Org Name:VELOCITY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-713-2600
Mailing Address - Street 1:2151 AIRLINE DR
Mailing Address - Street 2:SUITE 700
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3190
Mailing Address - Country:US
Mailing Address - Phone:318-550-2176
Mailing Address - Fax:
Practice Address - Street 1:2151 AIRLINE DR
Practice Address - Street 2:SUITE 700
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3190
Practice Address - Country:US
Practice Address - Phone:318-550-2176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VELOCITY MD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-19
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADO0000012261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA6215440002Medicare NSC