Provider Demographics
NPI:1609297449
Name:HIGHLAND CLINIC, A PROF MED CORP
Entity Type:Organization
Organization Name:HIGHLAND CLINIC, A PROF MED CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-798-4598
Mailing Address - Street 1:1455 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-798-4539
Mailing Address - Fax:318-798-4601
Practice Address - Street 1:1455 E BERT KOUNS INDUSTRIAL LOOP # 101
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5634
Practice Address - Country:US
Practice Address - Phone:318-798-4493
Practice Address - Fax:318-798-4450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-20
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty