Provider Demographics
NPI:1326331703
Name:SHOULDERS OF STRENGTH, INC
Entity Type:Organization
Organization Name:SHOULDERS OF STRENGTH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-235-4878
Mailing Address - Street 1:2900 CAMERON ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3714
Mailing Address - Country:US
Mailing Address - Phone:318-323-9995
Mailing Address - Fax:318-325-8943
Practice Address - Street 1:2800 YOUREE DR
Practice Address - Street 2:SUITE 350
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3661
Practice Address - Country:US
Practice Address - Phone:318-323-9995
Practice Address - Fax:318-325-8943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACM2701600000251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1925004Medicaid