Healthcare Provider Details

I. General information

NPI: 1639191315
Provider Name (Legal Business Name): COMPLETE VITAL CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 JACKSON STREET EXT EXT B
ALEXANDRIA LA
71303-2508
US

IV. Provider business mailing address

PO BOX 5047
MERIDIAN MS
39302-5047
US

V. Phone/Fax

Practice location:
  • Phone: 318-473-8800
  • Fax: 318-473-8005
Mailing address:
  • Phone: 800-447-4095
  • Fax: 601-482-7490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number4436 IR
License Number StateLA

VIII. Authorized Official

Name: GEORGE GARDINER
Title or Position: PRESIDENT
Credential:
Phone: 318-473-8800