Healthcare Provider Details

I. General information

NPI: 1194784173
Provider Name (Legal Business Name): MEDICAL INFUSION THERAPY OF LA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 DOCTORS DR
BOSSIER CITY LA
71111-3321
US

IV. Provider business mailing address

1525 DOCTORS DR
BOSSIER CITY LA
71111-3321
US

V. Phone/Fax

Practice location:
  • Phone: 318-741-1009
  • Fax: 318-741-1842
Mailing address:
  • Phone: 318-741-1009
  • Fax: 318-741-1842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number4428 IR
License Number StateLA

VIII. Authorized Official

Name: MRS. JEAN HOOGENDYK
Title or Position: OWNER - ADMINISTRATOR
Credential: RN
Phone: 318-741-1009