Provider Demographics
NPI:1417987116
Name:BEHAVIORAL HOSPITAL OF SHREVEPORT
Entity Type:Organization
Organization Name:BEHAVIORAL HOSPITAL OF SHREVEPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-943-5565
Mailing Address - Street 1:2025 DESOTO ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4717
Mailing Address - Country:US
Mailing Address - Phone:866-626-1840
Mailing Address - Fax:
Practice Address - Street 1:2025 DESOTO ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4717
Practice Address - Country:US
Practice Address - Phone:866-626-1840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA545283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA194072Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER