Provider Demographics
NPI:1700883063
Name:HOSPICE OF SHREVEPORT, INC.
Entity Type:Organization
Organization Name:HOSPICE OF SHREVEPORT, INC.
Other - Org Name:HOSPICE OF SHREVEPORT/BOSSIER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCDURMOND
Authorized Official - Suffix:
Authorized Official - Credentials:CHA, NFA
Authorized Official - Phone:318-865-7177
Mailing Address - Street 1:3829 GILBERT DR
Mailing Address - Street 2:MADISON PARK BUSINESS CENTER
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-5005
Mailing Address - Country:US
Mailing Address - Phone:318-865-7177
Mailing Address - Fax:318-865-4077
Practice Address - Street 1:3829 GILBERT
Practice Address - Street 2:MADISON PARK
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-5005
Practice Address - Country:US
Practice Address - Phone:318-865-7177
Practice Address - Fax:318-865-4077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA263251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1580201Medicaid
LA1580201Medicaid