Provider Demographics
NPI:1568714442
Name:DIABETIC LIFE PULSE OF LOUISIANA, LLC
Entity Type:Organization
Organization Name:DIABETIC LIFE PULSE OF LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:K
Authorized Official - Last Name:ADCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-286-3296
Mailing Address - Street 1:8575 FERN AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5677
Mailing Address - Country:US
Mailing Address - Phone:318-698-8889
Mailing Address - Fax:318-698-8893
Practice Address - Street 1:8575 FERN AVE STE 110
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5677
Practice Address - Country:US
Practice Address - Phone:318-698-8889
Practice Address - Fax:318-698-8893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-03
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08006R208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA261395Medicare PIN