Provider Demographics
NPI:1619353802
Name:HARRIS MEMORIAL PEDIATRIC & FAMILY CLINIC
Entity Type:Organization
Organization Name:HARRIS MEMORIAL PEDIATRIC & FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICE
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-205-4075
Mailing Address - Street 1:PO BOX 7312
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71137-7312
Mailing Address - Country:US
Mailing Address - Phone:318-205-4075
Mailing Address - Fax:318-754-4134
Practice Address - Street 1:4571 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-2917
Practice Address - Country:US
Practice Address - Phone:318-934-0097
Practice Address - Fax:318-934-0097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service