Healthcare Provider Details

I. General information

NPI: 1013494186
Provider Name (Legal Business Name): GPN-LEESVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 W FERTITTA BLVD
LEESVILLE LA
71446-4645
US

IV. Provider business mailing address

PO BOX 722345
NORMAN OK
73070-8774
US

V. Phone/Fax

Practice location:
  • Phone: 337-239-9041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRIS BEDDOE
Title or Position: CEO
Credential:
Phone: 318-256-5691