Provider Demographics
NPI:1346873031
Name:JUNE, MELVYN
Entity Type:Individual
Prefix:
First Name:MELVYN
Middle Name:
Last Name:JUNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3058 GORDONIA DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-5848
Mailing Address - Country:US
Mailing Address - Phone:318-519-8736
Mailing Address - Fax:
Practice Address - Street 1:3058 GORDONIA DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-5848
Practice Address - Country:US
Practice Address - Phone:318-519-8736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA009575064172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver