Provider Demographics
NPI:1790196657
Name:SPECIALISTS HOSPITAL SHREVEPORT
Entity Type:Organization
Organization Name:SPECIALISTS HOSPITAL SHREVEPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:318-213-3800
Mailing Address - Street 1:1500 LINE AVENUE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-213-3800
Mailing Address - Fax:
Practice Address - Street 1:1500 LINE AVENUE
Practice Address - Street 2:SUITE 206
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-213-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0113503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy