Provider Demographics
NPI:1295238327
Name:B&C ARCHERY LLC
Entity type:Organization
Organization Name:B&C ARCHERY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-658-0877
Mailing Address - Street 1:PO BOX 2494
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-2494
Mailing Address - Country:US
Mailing Address - Phone:318-255-3690
Mailing Address - Fax:318-251-6116
Practice Address - Street 1:1401 EZELLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-7218
Practice Address - Country:US
Practice Address - Phone:318-251-3126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD206301207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty