Healthcare Provider Details

I. General information

NPI: 1861915415
Provider Name (Legal Business Name): INTEGRA HEALTH SERVICES PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 RINGGOLD AVE STE B
COUSHATTA LA
71019-9004
US

IV. Provider business mailing address

PO BOX 53032
SHREVEPORT LA
71135-3032
US

V. Phone/Fax

Practice location:
  • Phone: 318-798-4606
  • Fax: 318-798-4601
Mailing address:
  • Phone: 318-798-4606
  • Fax: 318-798-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD.11956R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License NumberMD.11956R
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License NumberMD.11956R
License Number StateLA

VIII. Authorized Official

Name: DR. GAVIN F CHICO
Title or Position: MD/OWNER
Credential: MD
Phone: 318-780-6230