Provider Demographics
NPI:1720018492
Name:COMPLETE VITAL CARE, INC.
Entity Type:Organization
Organization Name:COMPLETE VITAL CARE, INC.
Other - Org Name:COMPLETE VITAL CARE, SHREVEPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-686-9995
Mailing Address - Street 1:411 ASHLEY RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7229
Mailing Address - Country:US
Mailing Address - Phone:318-747-9977
Mailing Address - Fax:318-747-9994
Practice Address - Street 1:2530 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 116
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3132
Practice Address - Country:US
Practice Address - Phone:318-686-9995
Practice Address - Fax:318-686-9997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4863-IR332B00000X, 332BC3200X, 332BP3500X, 332BX2000X, 333600000X, 3336C0003X, 3336H0001X, 3336L0003X, 3336M0002X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1275247Medicaid
=========016OtherTRICARE CORP SVC PROVIDER
LA1182190003Medicare NSC