Provider Demographics
NPI:1134260847
Name:ROARK, KITTY A
Entity type:Individual
Prefix:MRS
First Name:KITTY
Middle Name:A
Last Name:ROARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 PIERREMONT RD
Mailing Address - Street 2:SUITE 126
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-2084
Mailing Address - Country:US
Mailing Address - Phone:318-868-5851
Mailing Address - Fax:318-798-3348
Practice Address - Street 1:855 PIERREMONT RD
Practice Address - Street 2:SUITE 126
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2084
Practice Address - Country:US
Practice Address - Phone:318-868-5851
Practice Address - Fax:318-798-3348
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1137383Medicaid
LA1137383Medicaid