Healthcare Provider Details

I. General information

NPI: 1073365094
Provider Name (Legal Business Name): INJURYMD OF BOSSIER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2024
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5015 SHED RD STE 500
BOSSIER CITY LA
71111-5587
US

IV. Provider business mailing address

PO BOX 678111
DALLAS TX
75267-8111
US

V. Phone/Fax

Practice location:
  • Phone: 318-741-5858
  • Fax: 318-741-4496
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRADY CRENSHAW
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 318-751-9100